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Introduction: Neonatal hydrocephalus requires early recognition and appropriate surgical management to prevent long term sequalae. Definitive surgical management includes cerebrospinal fluid (CSF) diversion through a CSF shunt insertion, or neuro-endoscopic third ventriculostomy with or without choroid plexus cauterization. Surgical decision-making and the chosen approach are based on patient age, etiology, imaging, and comorbidities. Endoscopic third ventriculostomy (ETV) has been proven to provide a reasonable treatment option for hydrocephalus in children under 12 months of age. To our knowledge we report for the first time the application of indocyanine green fluorescence imaging to visualize the basilar artery during an ETV to prevent from harming the vessel. Patients and methods: A 7mo old patient with a history of preterm delivery at 27 weeks of gestation and intraventricular bleeding grade 2 developed consecutive hydrocephalus due to aqueductal obstruction. Indication was made for ETV. Results: ETV was carried out. During the procedure indocyanine green was applied to visualize the basilar artery prior to opening the floor of the third ventricle. This provided the surgical team with a clear picture of the anatomy thus enabling ETV while safely sparing the basilar artery. Discussion: ETV in infants are demanding procedures. The risk of harming the basilar artery is immanent as the vessel with its known anatomical variants cannot be clearly visualized through the floor of the third ventricle. With the application of indocyanine green fluorescence imaging this can be overcome providing an increased safety during the actual ETV. To our knowledge this is the first report on the use of indocyanine green fluorescence imaging for pediatric ETV. It might offer a new range of safety while providing minimal invasive neuro-endoscopic procedures to infant patients.

Bewerkstelligen einer wasserdichten, ausreichend weiten Anastomose zwischen dem proximalen und dem distalen Duodenum als Seit-zu-Seit Duodeno-Duodenostomie. Die laparoskopisch durchgeführte Operation, bereits 2001 von Bax und 2002 von Rothenberg beschrieben, ist technisch noch anspruchsvoller, bedingt durch die zuweilen schwierige Identifikation des insbesondere distalen Duodenums und den sehr kleinen «working space». Mit der Einführung eines Kind-gerechten 5mm Klammer-Naht-Geräts in jüngerer Zeit ergab sich die Möglichkeit, die Duodeno-Duodenostomie nicht mehr Hand-genäht, sondern mit Hilfe dieses «Staplers» durchzuführen. Wir berichten über die ersten Erfahrungen und Ergebnisse der komplett laparoskopisch durchgeführten Duodeno-Duodenostomie beim Neugeborenen.

L’opération de l’atrésie duodénale du nouveau-né est un défi et exige la réalisation d’une duodéno-duodénostomie latéro-latérale étanche et suffisamment large entre le duodénum proximal et distal. L’intervention laparoscopique, décrite déjà en 2001 par Bax et en 2002 par Rothenberg, est techniquement encore plus exigeante, à cause de la difficulté à identifier surtout le duodénum distal d’une part et de l’espace de travail très exigu d’autre part. Avec l’introduction, depuis peu, d’une agrafeuse chirurgicale 5 mm adaptée à l’enfant, il n’est plus nécessaire de suturer manuellement l’anastomose duodéno-duodénale mais on peut l’effectuer à l’aide de cette agrafeuse. Nous présentons les premières expériences et résultats de la duodéno-duodénostomie entièrement laparoscopique chez le nouveau-né.

ZusammenfassungDie Hydronephrose beim Kind ist zumeist bedingt durch eine (kongenitale) intrinsische Ureterabgangsstenose. Die von Anderson und Hynes etablierte „dismembered“ Nierenbeckenplastik stellt den Goldstandard in der operativen Therapie dar, sei es über einen offenen Zugang oder laparoskopisch (auch robotisch assistiert) bzw. retroperitoneoskopisch durchgeführt. Weniger häufig findet man – zumeist bei Patienten jenseits des Säuglingsalters − eine extrinsische Stenose als Ursache einer – dann zumeist – intermittierenden bzw. dynamischen Hydronephrose. Diese wird verursacht durch ein oder mehrere aberrierende Unterpolgefäße, welche den uretero-pelvinen Übergang obstruieren. Hierfür ist die operative Verlagerung des Gefäßes durch eine Tunnel-Plastik am Nierenbecken, die sog. „vascular hitch“-Operation, von Hellström beschrieben, in zunehmender Weise wieder etabliert worden. Die beiden Möglichkeiten der operativen Therapie werden nach wie vor kontrovers diskutiert. In der Literatur findet sich Evidenz dafür, dass bei Vorliegen eines Polgefäßes in bis zu 57 % zusätzlich eine intrinsische Stenose ist, in bis zu 100 % zumindest histologische Alterationen wie bei einer intrinsischen Stenose vorhanden sind. Der intraoperative Aspekt erlaubt keine Diskriminierung zwischen intrinsischer und extrinsischer Stenose, diese kann nur histologisch objektiviert werden. Bei der Durchführung eines „vascular hitch“ besteht daher das Risiko einer verbleibenden intrinsischen Stenose mit konsekutiver Abflussstörung und der Gefahr einer Partialfunktionsminderung. Auch kann durch den „vascular hitch“ selbst die Durchblutung der Niere kompromittiert werden. Die sog. „dismembered“ Nierenbeckenplastik vermeidet hingegen ein falsches Selektionieren der Patienten. Zudem ist sie mit hinreichender Evidenz belegt als ein Verfahren mit niedriger Komplikationsrate von 2 – 3 % und funktionell sehr guten Ergebnissen hinsichtlich des Erhalts der Partialfunktion und der Verbesserung der Abflussdynamik. Im Vergleich besteht in der Literatur kein vermehrtes Komplikationsrisiko gegenüber der „vascular hitch“-Operation. Daher bevorzugen wir die "dismembered" Nierenbeckenplastik als Methode der Wahl bei der Hydronephrose und dem Vorliegen eines aberrierenden Polgefäßes.

For ureteropelvic junction obstruction (UPJO), the standard of surgical care is dismembered pyeloplasty. This applies both for intrinsic but also for extrinsic etiology of the UPJO. When in 1995, Peters described for the first time laparoscopic pyeloplasty in children, the era of laparoscopic pediatric urological surgery began. Nowadays, laparoscopic dismembered pyeloplasty in children has evolved to become the gold standard. In this article, we report a standardized technique of laparoscopic transperitoneal dismembered pyeloplasty for infants and children. The described single steps of the procedure are reproducible regardless of age and weight and thus offer a high surgical success rate.

No abstract available., + ID der Publikation: unilu_51609 + Sprache: Englisch + Letzte Aktualisierung: 2021-11-04 11:45:42

The results of studies comparing two-dimensional (2D) and three-dimensional (3D) laparoscopy have shown variable results. We aimed to review the literature and develop an appropriate instrument to compare 2D and 3D laparoscopy. We further aimed to use the data extracted to perform a pilot study.Sixty-seven recent articles on 3D laparoscopy were reviewed and data extracted on factors influencing outcome variables. These variables were used to design a pilot study of 28 novices using a randomized crossover design. The results were analyzed using descriptive statistics and the Wilcoxon signed-rank tests.Seven themes were identified to influence the outcome of 3D studies: applied technique (1), experience of subjects (2), study design (3), learning curve (4), subjective qualitative reports (5), laparoscopic tasks (6), and chosen outcome variables (7). The consecutively developed five laparoscopic simulation tasks contained placing a rubber band over hooks, ring and pearl transfer, threading a pipe cleaner through loops, and placing a suturise. The pilot study showed a primary benefit of 3D laparoscopy that was unrelated to repetition. Two tasks served well to assess first-time performance, and two tasks promise to serve well to assess a learning curve if performed repeatedly.We were able to identify important issues influencing the outcome of studies analyzing 3D laparoscopy. These may help evaluate future studies. The developed tasks resulted in meaningful data in favor of 3D visualization, but further studies are necessary to confirm the pilot test results.

It is difficult to predict the risk of mortality in necrotizing enterocolitis (NEC). This study aimed at identifying risk factors for severe NEC (Bell stage III) and mortality in preterm children with NEC. In this multicenter retrospective study, we analyzed multiple data from 157 premature children with confirmed NEC in the period from January 2007 to October 2018. We performed univariate, multivariate, stepwise logistic regression, and receiver operator characteristics (ROC) analyses. We were able to demonstrate that low Apgar scores (notably at 1′ and 5′), low hemoglobin concentration (Hgb), and high lactate level at disease onset and during disease correlated with NEC severity and mortality (P Conclusion: Low Apgar scores, low Hgb, high lactate levels, and the presence of CHD or PDA correlated with severe NEC or mortality in children with NEC. What is Known:• It remains difficult to predict which infant that suffers from necrotizing enterocolitis at risk of death.• Several clinical and laboratory parameters tools to predict fatal outcome in NEC. What is New:• The following laboratory parameters were associated with the risk of death from NEC: Hemoglobin concentration, base excess and lactate level.• The following clinical variables were associated with the risk of death from NEC: Apgar scores, as well as the presence of congenital heart disease and patent ductus arteriosus.

Background Little is known about the timeframe in which acquired undescended testes occur. To guide recommendations for screening examinations, we aimed to (1) specify the ratio of acquired undescended testes in orchiopexy cases and to (2) identify a predisposing age for the development of acquired undescended testis. Methods Three-hundred-forty cases of orchiopexy were retrospectively analyzed and classified as congenital or acquired cases of undescended testis. In acquired cases, the time of the last documented physiological testicular position was obtained. The time of testicular ascent was approximated by calculating the mean between the last physiological finding and orchiopexy. Results In 151 cases (44.4%) prior physiological position of testes was documented and acquired undescended testis was assumed. In 115 of these cases (76.2%) details on the age at last physiological position were available. Ascent occurred between the age of one and fourteen. The 50th, 75th, 85th, 90th and 95th percentile for the estimated age at ascent was 5.8, 7.3, 8.4, 8.7 and 11.1 years, respectively. Conclusions Acquired undescended testes are a common cause of cryptorchidism. Ascent occurs throughout all prepubertal ages, emphasizing the need to regular follow-up of testicular position until puberty. Type of Study Prognosis study. Level of Evidence Level II.

Hydronephrosis in infants and children is most commonly due to a congenital, intrinsic obstruction of the uretero-pelvic junction. The Gold standard of care is defined as a dismembered pyeloplasty, nowadays mostly performed in a minimally-invasive procedure, either through a laparoscopic (also robotic-assisted) or retroperitoneoscopic approach. Less common is an extrinsic obstruction of the ureter or the uretero-pelvic junction caused by an aberrant crossing pole vessel, a condition more likely to affect children beyond infancy. This entity most often becomes apparent when it causes intermittent abdominal or flank pain. For this entity, Hellström described a surgical procedure avoiding dismembered pyeloplasty by hitching the crossing vessel in a tunnel at the pyelon. This has been increasingly advocated as a valuable therapeutic alternative to dismembered pyeloplasty. The discussion on whether dismembered pyeloplasty or a vascular hitch procedure is preferable to resolve the obstruction is controversial and ongoing. There is evidence in the literature that in the case of a crossing pole vessel an intrinsic stenosis of the ureter may additionally be present in up to 57 % of cases. However, this finding can only be proven histologically. The intraoperative aspect of a crossing pole vessel and the uretero-pelvic junction does not serve to discriminate between intrinsic and extrinsic stenosis. Therefore, a vascular hitch procedure bears the risk that a remaining intrinsic obstruction will be disregarded, which, in turn, may lead to urodynamic obstruction and consecutive loss of differential renal function. In addition, there is a general risk of compromising the perfusion of the affected kidney while hitching an aberrant vessel providing significant blood supply. Dismembered pyeloplasty can avoid a false selection of patients. In addition, there is sufficient evidence showing that dismembered pyeloplasty is a procedure with a low complication rate ranging from 2 to 3 %, providing very good results in functional outcome in terms of improving drainage and preserving differential renal function. Therefore, we prefer dismembered pyeloplasty as the method of choice for both the treatment of intrinsic as well as extrinsic uretero-pelvic junction obstruction.Die Hydronephrose beim Kind ist zumeist bedingt durch eine (kongenitale) intrinsische Ureterabgangsstenose. Die von Anderson und Hynes etablierte „dismembered“ Nierenbeckenplastik stellt den Goldstandard in der operativen Therapie dar, sei es über einen offenen Zugang oder laparoskopisch (auch robotisch assistiert) bzw. retroperitoneoskopisch durchgeführt. Weniger häufig findet man – zumeist bei Patienten jenseits des Säuglingsalters − eine extrinsische Stenose als Ursache einer – dann zumeist – intermittierenden bzw. dynamischen Hydronephrose. Diese wird verursacht durch ein oder mehrere aberrierende Unterpolgefäße, welche den uretero-pelvinen Übergang obstruieren. Hierfür ist die operative Verlagerung des Gefäßes durch eine Tunnel-Plastik am Nierenbecken, die sog. „vascular hitch“-Operation, von Hellström beschrieben, in zunehmender Weise wieder etabliert worden. Die beiden Möglichkeiten der operativen Therapie werden nach wie vor kontrovers diskutiert. In der Literatur findet sich Evidenz dafür, dass bei Vorliegen eines Polgefäßes in bis zu 57 % zusätzlich eine intrinsische Stenose ist, in bis zu 100 % zumindest histologische Alterationen wie bei einer intrinsischen Stenose vorhanden sind. Der intraoperative Aspekt erlaubt keine Diskriminierung zwischen intrinsischer und extrinsischer Stenose, diese kann nur histologisch objektiviert werden. Bei der Durchführung eines „vascular hitch“ besteht daher das Risiko einer verbleibenden intrinsischen Stenose mit konsekutiver Abflussstörung und der Gefahr einer Partialfunktionsminderung. Auch kann durch den „vascular hitch“ selbst die Durchblutung der Niere kompromittiert werden. Die sog. „dismembered“ Nierenbeckenplastik vermeidet hingegen ein falsches Selektionieren der Patienten. Zudem ist sie mit hinreichender Evidenz belegt als ein Verfahren mit niedriger Komplikationsrate von 2 – 3 % und funktionell sehr guten Ergebnissen hinsichtlich des Erhalts der Partialfunktion und der Verbesserung der Abflussdynamik. Im Vergleich besteht in der Literatur kein vermehrtes Komplikationsrisiko gegenüber der „vascular hitch“-Operation. Daher bevorzugen wir die "dismembered" Nierenbeckenplastik als Methode der Wahl bei der Hydronephrose und dem Vorliegen eines aberrierenden Polgefäßes.

Calcifying fibrous tumor (CFT) is a benign tumor entity which can present in a variety of different sites. Till date, eight cases with a mediastinal manifestation have been published in literature. Surgical removal is the treatment of choice for this often incidentally detected tumor. Surgery of thoracic CFT may be challenging due to its localization within the mediastinum. A 10-year old boy with a right-sided thoracic pectus carinatum-like deformity was referred for further evaluation, incidentally, revealing a mediastinal mass in computed tomography (CT). Laboratory results were all within normal range. Magnetic resonance imaging (MRI) showed a large tumor in the upper anterior mediastinum suggesting expansive but not infiltrative character. The tumor was displacing surrounding structures like the heart and the diaphragm. Lower venous stasis with dilation of the inferior cava vein could be demonstrated. The tumor was considered to be of benign dignity and surgical removal was indicated. Complete tumor resection could be achieved through a sternotomy approach, along with thymectomy. A partial resection of both the pericardium and diaphragm was required due to adhesion with soft tissue at those sites. The specimen's size was 320 mm × 145 mm × 100 mm, histologically confirmed as CFT. The patient showed no residual tumor at 3- and 9-month follow-up. This case is a report on a large mediastinal CFT which underwent successful complete surgical removal. Following tumor resection, prognosis is considered to be good; however, key issue is complete resection to avoid local tumor recurrence.

Varicocele is defined as an abnormal dilation and tortuosity of the internal spermatic veins found within the pampiniform plexus. It is a common finding in adolescents and adult men alike, however its diagnosis in the adolescent population poses different dilemmas in regard to indications for treatment than in adults. Failed Paternity is a clear-cut indication for repair in adult men attempting to father children. In adolescents, the physicians, family and patients must consider potential for future fertility problems which may or may not actually become of concern. Assessing the degree of negative effect of the varicocele on an adolescent's testicular health can also be difficult as teenagers typically are not asked to provide semen for analysis and thus surrogate markers for testicular health such as testicular size differentials must be used. Treatment options for the adolescent varicocele are similar to options in adult populations. While risks and benefits of various techniques can be considered, the gold standard for varicocele repair in adolescents has not been clearly defined. We aim to discuss diagnosis of varicocele, considerations for initiating treatment of varicocele in the adolescent, and techniques for management.

Uretero-pelvic junction obstruction (UPJO) is the most common cause of hydronephrosis in infants and children. Historically, this condition has been approached surgically through a retroperitoneal approach as described by Anderson and Hynes aiming for an open dismembered pyeloplasty. A true evolution of laparoscopy in pediatric urology took place within the last 30 years. Laparoscopy developed from a merely diagnostic tool for non-palpable testes to “interventional” laparoscopy for extirpative surgery. Finally the era of reconstructive pediatric laparoscopic urology started, when in 1995 Peters described the first laparoscopic pyeloplasty in a child. Laparoscopic dismembered pyeloplasty now has become the preferred surgical treatment of UPJO. It offers excellent visualization of the anatomy, accurate anastomotic suturing, thus the precise reconstruction of the UPJ along with good functional outcome. This article aims to provide the current status, indication and operative technique of laparoscopic dismembered pyeloplasty for UPJO in infants and children.

This study aimed to assess malpractice in paediatric minimally invasive surgery (MIS), and attitudes, prevention strategies and mechanisms to support surgeons while they are under investigation. An observational, multicentric, questionnaire-based study was conducted. The survey questionnaire was sent via mail, and it comprised four sections. Twenty-four paediatric surgeons (average age 54.6 years), from 13 different countries, participated in this study. The majority had >15 years of experience in MIS. Three (12.5%) surgeons reported a total of five malpractice claims regarding their MIS activity. The reasons for the claims were a postoperative complication in 3/5 (60%) cases, a delayed/failed diagnosis in 1/5 (20%) cases and the death of the patient in 1/5 (20%) cases. The claims concluded with the absolution of the surgeon in all cases, and monetary compensation to the claimant in two (40%) cases. Eleven (45.8%) surgeons were invited as expert counsels in medico-legal actions. Medico-legal aspects have a minimal impact on the MIS activity of paediatric surgeons. In this series, claims concluded with the absolution of the surgeon in all cases, but they had a negative effect on the surgeon’s reputation and finances. A key element in supporting surgeons while they are under investigation is always to choose a surgeon who is an expert in paediatric MIS as legal counsel. A constant update on innovations in paediatric MIS and appropriate professional liability insurance may also play a key role in reducing medico-legal consequences.

Over the last 10–15 years, the management of appendicitis in childhood has changed with regard to diagnosis and therapy. From the first report of conventional appendectomy in 1894 for decades, appendectomy through an incision as described by McBurney [1] has been the gold standard in surgical treatment of (suspected) acute appendicitis. The implementation of ultrasound, scoring systems to support the surgical indication, and minimal invasive techniques for surgery since the 1980s which nowadays range from conventional laparoscopy to single-site surgery have had major impact in the treatment of appendicitis. The aim is to propose practical clinical guidelines for the current gold standard of laparoscopic appendectomy.

Duplication of the renal system is one of the most common congenital anomalies of the urinary tract. The majority of these anomalies remains clinically silent. A smaller number of them become evident as a consequence of hydronephrosis, vesicoureteral reflux (VUR), or incontinence. Recently, antenatal diagnosis permits to identify many urologic anomalies, including different variants of ureteral duplications, which are clinically asymptomatic. A duplex renal system often has one moiety that is either poor or nonfunctioning. In these cases, there is an indication to remove surgically the nonfunctioning moiety.

Ureteropelvic junction obstruction (UPJO) is the most common cause of hydronephrosis in infants and children. Since Anderson and Hynes described their technique of open dismembered pyeloplasty through a retroperitoneal approach, this has been considered the gold standard in surgical care for UPJO. When in 1995 Peters reported on the first pediatric laparoscopic pyeloplasty, a new era for laparoscopy in pediatric urology began. For the first time reconstructive surgery on the upper urinary tract was hereby implemented. Meanwhile pyeloplasty in children either by a laparoscopic or a retroperitoneoscopic approach has become an established technique to operate on UPJO in infants and children. The aim is to propose practical clinical guidelines for the current gold standard of laparoscopic dismembered pyeloplasty.

Necrotizing fasciitis (NF) is a severe, life-threatening infectious condition. Diagnosis is difficult due to unspecific symptoms yet crucial for favorable outcomes. We report a case of a 1 year old, previously healthy boy, where early suspicion of NF led to prompt aggressive therapy and consecutive restitutio ad integrum.

Application of laparoscopy in pediatric urology has evolved over more than 30 years coming from a merely diagnostic use for non-palpable testes to "interventional" laparoscopy to extirpative surgery and finally to the era of reconstructive pediatric laparoscopic urology, when in 1995 Peters described the first laparoscopic pyeloplasty in a child. Laparoscopic surgery in pediatric urology became implemented increasingly in the twenty-first century with now present-day applications including the complete variety of all kind of indications for surgery for pediatric urological pathology. This article aims to provide a comprehensive overview of current indications, techniques, and outcomes of laparoscopic transperitoneal surgery of the upper as well as of the lower urinary tract for urological pathology in the pediatric patient population.

Introduction: Most of the children with hydronephrosis do not require any surgical intervention. However, in individual cases, irreversible loss of renal function can develop. Predictive criteria have been proven ineffective so far in determining in which children obstruction will lead to renal damage. The aim of our retrospective study was to determine the role of a crossing lower pole vessel (CV) in children undergoing pyeloplasty. Materials and methods: Between 1996 and 2003, 137 patients (age between 6weeks and 16years) with unilateral ureteropelvic junction obstruction and no associated urological pathologies underwent Anderson-Hynes dismembered pyeloplasty. A total of 112 patients were evaluated with complete data. One of the following criteria was considered to be indication for surgery in children with grade 4 hydronephrosis: differential renal function (DRF) 10% and washout patterns II or III b according to O'Reilly. We looked at the age during surgery and the kind of presentation. DRF was measured using diuretic renography preoperatively and 1year postoperatively. A postoperative change in DRF of group A (children without CV, n=84) was compared to that in group B (children with CV, n=28). Results: Median age at the time of surgery was 5months in group A compared to 23months in group B. Only in 21.4% of the children with CV compared to 60.7% without CV hydronephrosis was diagnosed by ultrasound examination antenatally. We found a preoperative DRF of 42.4%±11.2 SD in group A, and of 38.9%±11.7 SD in group B. The percentage of postoperative improvement was 3.3% in group A and 15.4% in group B. Conclusions: Children with ureteropelvic junction obstruction and CV received a delayed surgical treatment and showed a greater reduction in differential renal function preoperatively, in contrast to patients without CV. Our data show that CV is a risk factor for deterioration of renal function in children with hydronephrosis and we advocate for an early pyeloplasty in these children, especially if they have a high-grade dilatation and equivocal washout patterns in diuretic renographies. Further prospective studies are necessary in order to understand the natural history of CV and to reveal the importance of the crossing lower pole vessel as a structural anomaly lacking maturation

Introduction Nonischemic priapism (NIP) in childhood is a very rare affection. In the literature, patients with NIP are described mainly incidental after perineal trauma. Many of them underwent embolization of either internal pudendal artery or bulbocavernosal arteries. Patients and Methods We report on six boys between 4 and 13 years of age with NIP, treated at our institution between 2008 and 2014. Color Doppler ultrasound (CDU) was performed in all patients as emergency diagnostic evaluation. Patients were treated conservatively, including bed rest, local cooling, and perineal compression. History, etiological factors, clinical findings, diagnostics, and follow-up are presented. Results Out of the six patients, only one boy had a history of perineal injury with subsequent arteriocavernosal fistula, revealed in CDU. Five patients were circumcised, and one of them suffered from thalassemia minor, but no other underlying disease or etiological factors could be found. In all patients, normal to high blood flow velocities were detected in the cavernosal arteries. Detumescence started with nonoperative treatment within 24 hours in five boys and in one patient with recurrent priapism after 1 week. All six patients remained painless without evidence for an ischemic priapism. None of them suffered from relapse and further erections were observed during follow-up from 3 to 87 months. Conclusion In contrast to the literature, five out of six boys developed NIP without a previous perineal trauma. The etiology of idiopathic NIP in childhood remains unclear; however, circumcision may play a role as a conditional factor. One etiological thesis could be the release of the neurotransmitter nitric oxide after stimulation of the corpora cavernosa. Conservative treatment proved to be successful in all six patients. During a median follow-up of 55 months (3–87 months), none of the patients showed signs of erectile dysfunction.

Purpose We set out to evaluate how residents in pediatric surgery learn and how they teach. We hypnotized that European residents learn as much from their peers and teach as much as their fellows worldwide, but that they receive comparably less educational training. Methods An online questionnaire was distributed to the participants of the combined annual meeting for German, Swiss and Austrian residents in pediatric surgery. Participants were asked whom they learn from in different workplace environments (ward, operating room, emergency department), how, when and why they adopt the role of teacher and how they were prepared for this role. Results Response rate was 48%. 65 questionnaires were analyzed. Residents stated that they predominantly learn from each other on wards and in the emergency department, less frequently in the operating room. They ranked fellow residents as first or second most important source of instruction. 53% of participants have never had any educational training, for another 33% the instruction was being done by fellow residents without any set curriculum. 93% of the participating residents had no or did not know about any resident as teacher training program available to them. Nevertheless, motivation to teach was stated to be high and interest in educational training was assured. Conclusions Our data delivers evidence that peer teaching during residency is the rule rather than the exception in Central Europe. Educational training however is scarce. Resident as teacher-training programs need to be introduced. Next to local initiatives, we strongly recommend national initiatives powered by regulatory authorities and surgical associations. Type of study Research paper. Level of evidence II.

We describe a 99-day old girl with inspissated bile syndrome (IBS) unresponsive to treatment with oral ursodeoxycholic acid. We performed a pure laparoscopic 2-stage procedure, consisting of cholecystostomy and insertion of an indwelling balloon catheter for local ursodeoxycholic acid flushing for 13 consecutive days. Subsequently, the cholecystostomy was removed, preserving the gallbladder using the same laparoscopical approach when bilirubin values returned to normal and bile duct obstruction was no longer detectable radiologically. This is the first report of an exclusively laparoscopic management of IBS.

Introduction Pediatric necrotizing fasciitis (NF) is a rare but severe, life-threatening infection. Early diagnosis is crucial to reduce morbidity and mortality, but initial symptoms are nonspecific. Little sound data exists on factors aiding clinicians to recognize NF in children. With a systematic literature review, we aimed to better characterize pediatric NF. We focused on triggers, symptoms, and laboratory and microbiological findings and differences between pediatric adult patients. Materials and Methods A literature research was conducted according to the guidance of the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses.” Articles published between January 2010 and October 2015 were included. Data extraction was performed as an iterative process. Results A total of 32 articles describing 53 pediatric patients with NF were included in the analysis. Overall mortality was 15.4%. Frequency peaks were found for neonates and children aged between 1 and 2 years. These two age groups were predominantly affected on the torso. Another frequency peak was found in patients aged around 10 years of age. These patients were predominantly affected on the extremities and face. In general, early symptoms were found to be fever, erythema, localized selling, and tenderness or pain. “Pain out of proportion” was not mentioned as a typical symptom. Fever and leukocytosis were more common in teenage patients. Monomicrobial necrotizing (type 2) fasciitis was much more common than polymicrobial (type 1) fasciitis. Next to Streptococci and Staphylococci, Pseudomonas aeruginosa was often isolated. Early aggressive surgical treatment was the treatment of choice. Conclusions Pediatric NF has distinguishing features that differ from adult NF. Knowledge of these details should increase early diagnosis and improve treatment.

Bilateral nephroblastoma involving the renal hilus represents a significant surgical challenge. Different operative strategies have been proposed for this condition. We analyzed the outcome of simultaneous bilateral partial nephrectomy for complex stage V nephroblastoma.We retrospectively analyzed patients with bilateral nephroblastoma involving the renal hilus operated on at our institution between 2002 and 2008. We assessed patient data and surgical and oncologic outcomes.We analyzed data from 5 patients with a median age of 27 months at surgery (range 13 to 58). Two children had additional pulmonary metastases. Patients were treated according to the International Society of Pediatric Oncology 2001/German Society of Pediatric Oncology and Hematology protocol. All children underwent synchronous bilateral nephron sparing surgery (longitudinal partial nephrectomy or enucleation) of the central tumors. Median operating time was 182 minutes (range 129 to 291), with vascular exclusion performed in 4 patients (7 to 25 minutes). Complications consisted of urinary leakage in 2 cases. Postoperative renal function was unimpaired in 4 patients and 1 patient had Wilms tumor/aniridia/genitourinary malformations/retardation syndrome with glomerulopathy. One patient with pulmonary metastases and blastemal histology had multiple pulmonary relapses and died due to pulmonary progressive disease. Four patients are alive without evidence of disease at a median followup of 45 months (range 44 to 73).Surgery for central stage V nephroblastoma is possible with good functional and oncologic outcomes. The single stage approach is safe, provided that operating and treating physicians have sufficient expertise with such conditions. The ultimate goal is to avoid tumor nephrectomy.

Objective Laparoscopic or retroperitoneoscopic pyeloplasty for ureteropelvic junction obstruction in children has become a routine procedure. The aim of this study was to evaluate functional outcome for patients who had undergone a laparoscopic dismembered pyeloplasty. Patients and methods Seventy children underwent a laparoscopic dismembered pyeloplasty. Median follow up was 24 months (1–48). We reviewed differential renal function (DRF) and tracer clearance with diuretic renography before as well as 3 and 12 months after operation. Ultrasound was used to determine the grade of hydronephrosis pre- and postoperatively. Results Median age at operation was 20 months (1–178). Median operating time was 140 min (95–220). Mean DRF could be preserved with no significant difference (P > 0.05). All patients showed a significant improvement in tracer clearance on diuretic renography postoperatively (P

Summary Background Vascular clamping techniques are commonly used but so far the impact on pediatric liver surgery has not been investigated. The purpose of this study was to analyze pedicle clamping during pediatric liver resection in terms of hepato-cellular injury and blood loss. Methods Sixty-seven children undergoing liver resection were analyzed retrospectively. Vascular clamping was used in 28 cases (PC group), in 39 the resection was performed without clamping (NPC group). Major hepatectomies (resection of more than three segments) were carried out in 88%, minor hepatectomies (resection of three and less segments) in 12% of patients. Twenty-six children underwent extended liver resection. Patient data, liver function tests (LFTs) and blood loss were analyzed statistically. Results There were no significant differences in patient preoperative and postoperative data and LFTs between the groups. Within the NPC group the amount of administered fresh frozen plasma (FFP) in total and per kilogram (FFP/kg) was significantly higher (p=0.023 and 0.028) than in the PC group. For patients with extended liver resection, operation times were significantly longer (p=0.016) in the group without vascular clamping (NPCext). In the NPCext group significantly more children required packed red cells, FFP and FFP/kg. LFTs showed no significant differences in all children regardless of vascular clamping. Conclusions For children undergoing liver resection, vascular clamping offers a blood saving surgical technique. Postoperative LFTs were not statistically different, regardless of vascular clamping. Pedicle clamping proved to be a safe method, not associated with an increase in perioperative complications.

There are only few pediatric surgical centers across the world with expertise for minimally invasive anatomical lung resections in children. Between September 2003 and September 2005, 67 children underwent thoracoscopic surgery at the Department of Pediatric Surgery, University Hospital of Tuebingen, Germany. In 19 of these cases a lung resection was carried out, 8 of them had an anatomical lung resection. All patients underwent general anesthesia without selective intubation for the procedure. Intrathoracic pressure with insufflation of carbon dioxide of 1.5 l / min was held at 3-5 mmHg. Two 5 mm ports for video and instruments and one 12 mm port for a stapling device were used. Resected lung specimens were removed from the thorax through an additional 2-3 cm long incision. A bronchoscopy was carried out during surgery in all patients. Median age at operation was 5.6 years (range 3 months-20 years). Median operation time was 150 minutes (range 94-250 min). Conversion to open surgery was performed in 3 cases. This was due to bleeding in one child, due to a stiff lung in another patient with cystic fibrosis and due to a vascular and bronchial malformation in a third child suffering from middle lobe syndrome. There were no postoperative complications. Our preliminary results show, that thoracoscopic lung resections in children can be performed without major complications and excellent cosmetic results. For the necessity of a conversion to open surgery possible reasons may be insufficient intrathoracic overview as well as congenital anomalies of the vascular and / or the bronchial tract. Co-morbidities such as rib-fusion, deformities of the thorax or scoliosis can be avoided using thoracoscopic procedures.

Purpose Three-dimensional visualization of solid tumors is possible because of high-resolution computed tomography and magnetic resonance imaging scans. However, additional preoperative information is often desirable in complex malignancies. For the first time, the authors present a model of preoperative 3-dimensional visualization and virtual resections in pediatric solid tumors. Methods Image analysis of various pediatric tumors was performed using the research software HepaVision2 (MeVis, Bremen). Organs, tumors, and the vascular system were extracted from multislice computed tomography scans. After hierarchical analysis of the vascular system, territories supplied or drained by the major vascular branches were calculated. Results were explored and virtual resections of organs were carried out using the research software InterventionPlanner (MeVis, Bremen). Data were correlated to intraoperative findings. Results Four hepatic malignancies, 4 renal tumors, and 3 other neoplasms were analyzed. The technique of 3-dimensional visualization was feasible for all investigated children (mean age 5 years and 9 months). Spatial relations between physiological and pathological structures were identified, and anatomical structures (vessels, tumor tissue, and organ parenchyma) were determined using colorimetric encoding. Virtual simulations of tumor resection were used successfully for planning of surgical procedures in the hepatic and renal tumors. Conclusions The technique of 3-dimensional tumor visualization and virtual simulation of tumor resections provides the basis for a successful planning of complex tumor resections in children. The efficiency of these techniques should be further analyzed in series with higher numbers and differentiations of tumors.

Mit Beginn dieses Jahrtausends haben minimal-invasive Techniken in der Chirurgie einen festen Stellenwert, so auch in der Kinderchirurgie und -urologie.Die Autoren sehen Vorteile im laparoskopischen Vorgehen bei der Nephrektomie und der Heminephrektomie. Bei der Durchfuhrung einer Nierenbeckenplastik favorisieren sie zurzeit noch die konventionelle Operation.Beim vesikoureteralen Reflux kommen beide Verfahren zur Anwendung. Zu berucksichtigen sind Refluxrezidive und Nebenwirkungen injizierter Substanzen bei der Unterspritzung von Harnleitern. In der akuten Behandlung der symptomatischen Ureterozele hat die endoskopische Schlitzung ihren festen Platz, die definitive Versorgung bleibt jedoch – insbesondere bei den ektopen Formen – dem offenen Vorgehen mit Neueinpflanzung des oder der Harnleiter vorbehalten. Unstrittig ist die endoskopische Therapie der Urethralklappen.Unabdingbar wird aber auch in Zukunft sein, bei allen Vorteilen der laparoskopischen Chirurgie ihre Indikation, ihre Machbarkeit und ihre Uberlegenheit gegenuber offen chirurgischen Verfahren kritisch zu prufen.

Objective To demonstrate a rare case of urological pathology, we report a combination of a single kidney and ureteral atresia. The treatment concept and outcome are outlined. Patient and method Antenatal ultrasound had revealed urinary ascites which lead to caesarean section in the 34th gestational week. Persisting anuria was confirmed postnatally and peritoneal dialysis started on the second day of life. Subsequent laparotomy revealed ureteral atresia after 3 cm of patent ureter. We created an ileum conduit after discussing various other therapeutic options. Result and conclusion A follow up of 12 months has shown steady function of the stoma with stable renal parameters. An ileal conduit represents a good option if high drainage is necessary in early childhood.

Jusqu’a l’âge de 6 mois, le testicule peut encore descendre spontanement et il est ainsi possible d’attendre jusqu’a cet âge avant de pratiquer une operation. Une cryptorchidie doit toujours etre operee.

Bis zum Alter von 6 Monaten kann der Hoden noch spontan deszendieren, so dass bis dahin mit einer Operation zugewartet werden kann. Ein Kryptorchismus, und somit auch ein Gleithoden, muss immer operiert werden.

Management of appendicitis in children has changed remarkably over the last decade. The proven benefits of laparoscopic appendectomy (LA) over the open operation have made LA increasingly popular for pediatric patients. To date, no national clinical practice guideline is available for pediatric LA in Germany and the operation is not standardized. Thus, the aim of our study was to evaluate the current status of pediatric LA in Germany.An internet-based survey was conducted on pediatric LA among all 98 registered pediatric surgical units in Germany, comprising 22 questions with regard to utilization and subjective appraisal of LA, technical standards, perioperative treatment, and training aspects.The survey was completed by 71 of the 98 units (72%). Technical infrastructure for LA was provided in all units, but only in 79% of the units was LA, the standard approach for appendectomy. Overall quality of LA was rated better compared with open appendectomy by 52% units, equivalent by 38% and worse by 3%. The three-port technique was used by 90% of the units; 10% used a single-port approach. Dissection of the mesoappendix was done with bipolar coagulation in 55%, monopolar coagulation in 24%, harmonic knife in 6%, and endostaplers in 11% of the units. Closure of the appendiceal stump was performed using endoloops in 57%, ligations in 3%, endostaplers in 39%, and harmonic knife in 1%. Removal of the appendix was done through the port by 79%, using a retrieval bag by 18%, whereas in 3% it was removed directly through laparotomy. In case of appendiceal perforation, an intra-abdominal drain was placed in 65%. Perioperative antibiotic treatment for nonperforated appendicitis was given as a single shot in 33% of the units, for 24 hours in 17%, for 3 days in 39%, and for 5 to 7 days in 11%. LA was performed by a trainee under supervision in 87%, by a board approved pediatric surgeon in 2%, by an attending pediatric surgeon in 7%, and by the surgeon-in-chief in 4% of the units. For 93% of the sample, LA was an essential part of pediatric surgical training.LA is the favored surgical method for pediatric appendectomy in Germany. However, technical details, perioperative therapy and implementation into training programs remain inconsistent. An effort has to be made to establish national clinical practice guidelines to achieve standardization of LA.

Laparoendoscopic single-site surgery (LESS) in pediatric patients has emerged as a viable alternative to standard laparoscopy. The aim of our investigation was to assess different surgical approaches for LESS, stratifying by weight.From March 2010 to April 2012 LESS was performed in 42 children. Children weighing below 10 kg underwent LESS through an umbilical incision using two 3-mm trocars and one 5-mm trocar. Patients above 10 kg were operated on using a metal multiuse single-site single port (X-Cone; Karl Storz Endoskope, Tuttlingen, Germany). Conventional straight laparoscopic instruments were used in all cases.Mean age at operation was 100 months (range, 0.25-207 months), and mean weight was 27 kg (range, 3.1-82 kg). Median operating time was 74 minutes (range, 36-300 minutes). Eighteen children underwent LESS using two 3-mm trocars and one 5-mm trocar; 1 case required two 5-mm trocars and one 10-mm trocar. Twenty-three patients were operated on with the multiuse device. All operations were carried out safely in a standard laparoscopic transperitoneal technique with full achievement of the surgical target. In none of the patients was an intraoperative complication noticed. Postoperatively two complications were noted, which resolved spontaneously.LESS for pediatric patients can be done safely and efficiently with even less trauma than in conventional laparoscopy irrespective of age and weight. However, different surgical approaches have to be considered as disposable single-site ports are not available for infants and small children. To decrease operative expenses, conventional multiuse trocars and a multiuse single-site port were used with conventional laparoscopic instruments.

A case of a newborn with atresia of the transverse colon and right facial hemiaplasia, anophthalmia, and cerebral dysfunction is reported. Colon atresia is a rare cause of congenital bowel obstruction and often associated with other malformations such as abdominal wall defects, gastrointestinal, cardiac, urogenital, and musculosceletal lesions. Facial hemiaplasia may arise in frame of chromosomal defects or as a result of neurovascular compromise caused by congenital amniotic bands. However, the combination of colon atresia and facial hemiaplasia has not been reported before.

Thoracoscopic approach for repair of esophageal atresia (EA) and tracheo-esophageal fistula (TEF) has become a standard procedure in many pediatric surgical centers. Thoracoscopic surgery in a newborn is demanding from both the surgeon and the patient. The potential benefits for the newborn are still discussed by neonatologists, pediatric intensive care physicians, and also parents. The aim of our investigation was to clearly define perioperative outcome and complication rates in children undergoing thoracoscopic versus open surgery for EA and TEF repair.We reviewed the records of 68 newborns undergoing surgery for EA and TEF between March 2002 and February 2010. Patient data of open versus thoracoscopic approach were compared regarding operating time, intraoperative as well as postoperative pCO(2)max values, postoperative ventilation time, and complications. Specific patient data are reported with the median and range. Data analysis was done with the JMP(®) 7.0.2 statistical software (SAS Institute, Cary, NC).For the 68 patients, the mean gestational age was 35 weeks (28-41), the median birth weight was 2720 g (1500-3510 g) in the thoracoscopic group and 2090 g (780-3340 g) in the open group. There were 36 girls and 32 boys. Thirty-two children had associated anomalies. Twenty-five children were undergoing a thoracoscopic procedure. In 8 cases, the operation was converted to open thoracotomy. Another 32 children received a thoracotomy. In 11 newborns, a cervical esophagostomy was performed because of long-gap EA and these patients were excluded from the study. Operating time was 141 minutes (77-201 minutes) in the thoracoscopic group and 106 minutes (48-264 minutes) in the thoracotomy group, with significant difference (P=.014). Values of pCO(2)max during operation were 62 mm Hg (34-101 mm Hg) in the thoracoscopic group and 48 mm Hg (28-89 mm Hg) in the open group, with significant difference (P=.014). Postoperative ventilation time was 3 days (1-51 days) in all groups, with no significant difference (P=.79). Early complications were noticed in 9 children undergoing thoracoscopy and in 8 patients of the thoracotomy group, again with no significant difference (P.05).Thoracoscopic repair of EA with TEF is justified because of a comparable perioperative outcome to open surgery, competitive operating times, decreased trauma to the thoracic cavity, and improved cosmesis despite skeptical considerations. Complication rates are not higher than in children operated on through a thoracotomy. However, a learning curve has to be taken into account and large experience in minimal invasive surgery is mandatory for this procedure. Larger series have to be expected for a more objective evaluation of perioperative as well as long-term outcomes. To our opinion, the thoracoscopic approach appears to be favorable and could be a future standard.

OBJECTIVE: Aim of the study was to evaluate the outcome of augmentation cystoplasty and bladder substitution in a pediatric age group. METHODS: Patient records of all children who underwent reconstructive bladder surgery between October 1999 and November 2007 were reviewed. Additionally, standardized interviews were performed to evaluate the postoperative outcome. RESULTS: Augmentation cystoplasty and bladder substitution were performed in 19 and 6 patients, respectively. 21 patients underwent continent catheterizable vesicostomy. Postoperative urodynamics revealed a significant increase in bladder volume (median 400 ml) as well as a significant improvement in bladder compliance (median 13.5 ml/cmH 2 O). 90% of the patients were reported to be socially continent. Renal function remained stable in 95% and decreased in 5% of the children. Major complications were lower urinary tract calculi (39%), stricture or insufficiency of the continent vesicostomy (28%), and intestinal obstruction (9%). No malignancies associated to bladder augmentation or substitution were detected yet. CONCLUSION: Augmentation cystoplasty and bladder substitution preserve renal function and provide urinary continence in most children with intractable lower urinary tract disease. However, the procedures remain associated with numerous complications.

In patients with maljunction of pancreatic and common bile duct (CBD)-defined as a long common pancreaticobiliary channel (LCPC)-a resection of the CBD and a hepaticojejunostomy is recommended. To date, this operation is usually performed through an open approach. In this article, we report on our experience with minimally invasive surgery (MIS) for LCPC in children.From 2004 to 2008, 7 children underwent MIS for LCPC. Mean age at operation was 46 months. Two patients had a choledochal cyst (Todani type IV) additionally. Diagnosis was made preoperatively by magnetic resonance cholangiopancreaticography, in 5 children confirmed by endoscopic retrograde cholangio-pancreaticography. A four-trocar technique was used for the laparoscopic approach. Follow-up examinations included laboratory tests, ultrasound, and scintigraphy.A Roux-en-Y hepaticojejunostomy was performed in all patients-in 6 children completely by laparoscopy. In 1 child, the operation was converted to open after CBD diversion due to a large, vulnerable liver. In 2 children with extended choledochal cyst, additionally, a reconstruction of the separated hepatic ducts was performed. Reresection of a CBD stump was carried out by laparoscopy in another patient. A leakage of the anastomosis occurred in 1 child.The laparoscopic approach for pathology of pancreaticobiliary ducts might be a new alternative for surgical treatment in infants and children. It can also be performed in cases with choledochal cyst involving the hepatic ducts and for reresection of remnants of CBD.