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General surgery resident participation in the operating room is critical in training the next generation of surgeons. As of yet, the impact of resident participation on outcomes of surgery for pectus excavatum and many complex subspecialty operations has not been well studied.A multi-institutional retrospective study of patients undergoing operative repair for pectus excavatum was performed. All relevant data were analyzed (IRB 11144).Two hundred and fourteen patients underwent operative correction (195 Nuss, 19 Ravitch). There were 185 males. Average age at repair was 14.7 years with a Haller index of 4.5. Average surgery time was 144 minutes (57-255) for the Nuss procedure and 263 minutes (141-373) for the Ravitch procedure. The presence of a second pediatric surgeon reduced the surgery time from 170 to 135 minutes (p0.01) and the presence of residents increased the time from 129 to 155 minutes (p0.01) for the Nuss procedure. One hundred and fifty patients had a single bar and 57 patients had 2 bars (28%). Average length of stay was 4.96 days (3-11). Long-term follow-up averaged 1737 days (42-3894). There were few complications and no difference in complication rate or length of stay between groups. Ninety nine percent of patients deemed the repair excellent and no patients required revision.Resident participation increases operative time, but with no demonstrable effect on hospital stay or long-term outcomes. Complication rates are low regardless of operating team composition. Thus, continuing to allow resident involvement, especially in subspecialty operations such as the Nuss and Ravitch procedures, may be worthwhile for resident education and surgical experience.

Background Morgagni hernias are rare, with a reported incidence of 2% to 5% of congenital diaphragmatic hernias. Objectives To review a laparoscopic technique to repair Morgagni hernias in pediatric patients. Methods Retrospective chart review of pediatric patients who underwent minimally invasive repair of a Morgagni hernia from November 2009 to September 2017 within a defined population. Results During an 8-year period, 15 patients with Morgagni hernias were identified. Four patients with Morgagni hernias were excluded because they had open repairs. Eleven Morgagni hernias were repaired through a completely minimally invasive approach. Three repairs were completed using a soft-tissue patch (Gore-Tex patch, W L Gore & Associates Inc, Flagstaff, AZ). All minimally invasive repairs were completed with transfascial sutures using an endoscopic suturing device (Endo Close, Covidien/Medtronic, Fridley, MN) and 2-0 nonabsorbable synthetic sutures with extracorporeal knot tying. Median follow-up was 40 months (range = 2.6 months to 7.3 years). No patients had postoperative pectus excavatum defects. There were no recurrences. Conclusion Morgagni hernias are amenable to minimally invasive repair with this simple technique. With large defects, synthetic patches should be used. Recurrences are rare, and morbidity is low.

Background Reconstruction of complex chest wall deformities is a surgical challenge. A new technique can improve long-term outcomes and result in high patient satisfaction. Methods A multicenter study was conducted on pediatric patients undergoing complex chest wall reconstruction between September 2015 and January 2018. The evolution of the technique using open reduction and internal fixation (ORIF) with SternaLock® and RibFix® to repair chest wall deformities is described. Results Seventeen patients underwent complex chest wall reconstruction with ORIF. Eight patients had severe or recurrent pectus excavatum, five patients had pectus carinatum, and four patients had complex chest wall fractures or other anomalies causing significant chronic pain. Up to three SternaLock® plates and four RibFix® plates were used for each procedure. Median length of hospital stay after surgery was four days. Median follow-up time was 12 months (range 2–30). There were no postsurgical complications. There was 100% patient satisfaction in postoperative recovery and cosmesis. Conclusion ORIF using SternaLock® and RibFix® is an effective method of reconstructing complex chest wall deformities. This technique improves physical stability without the requirement of a subsequent surgery and enhances overall patient satisfaction. High volume centers should integrate this novel approach for challenging chest wall reconstruction. Type of study Treatment study: case series. Level of evidence Level IV.

Context Increasing popularity of strong magnets as toys has led to their ingestion by children, putting them at risk of potentially harmful gastrointestinal tract injuries. Objectives To heighten physician awareness of the potential complications of magnetic foreign body ingestion, and to provide an updated algorithm for management of a patient who is suspected to have ingested magnets. Design A retrospective review of magnet ingestions treated over a two-year period at our institutions in the Southern California Permanente Medical Group. Data including patient demographics, clinical information, radiologic images, and surgical records were used to propose a management strategy. Results Five patients, aged 15 months to 18 years, presented with abdominal symptoms after magnet ingestion. Four of the 5 patients suffered serious complications, including bowel necrosis, perforation, fistula formation, and obstruction. All patients were successfully treated with laparoscopic-assisted exploration with or without endoscopy. Total days in the hospital averaged 5.2 days (range = 3 to 9 days). Average time to discharge following surgery was 4 days (range = 2 to 7 days). Ex vivo experimentation with toy magnetic beads were performed to reveal characteristics of the magnetic toys. Conclusions Physicians should have a heightened sense of caution when treating a patient in whom magnetic foreign body ingestion is suspected, because of the potential gastrointestinal complications. An updated management strategy is proposed that both prevents delays in surgical care and avoids unnecessary surgical exploration.

Recurrent gastroesophageal reflux is a common complication after fundoplication procedures. We report our experience with laparoscopic redo Nissen fundoplications in pediatric patients with a history of open antireflux procedure. The medical records of all patients with a history of open antireflux procedure who underwent a subsequent laparoscopic redo Nissen fundoplication were reviewed. One hundred eighty laparoscopic Nissen fundoplications were performed between September 2004 and September 2012; 23 were redo procedures. Twelve patients had a history of prior open fundoplication. Average time between operations was 113.7±64 months. Seven patients presented with emesis, 4 with aspiration pneumonia, and 1 with clinical reflux. Eight had a history of cerebral palsy and/or seizure disorder. Laparoscopic revision was completed in 100% of the patients, with no intraoperative complications. Average operative time was 177.5±86 minutes. Seven patients were able to resume feeds on postoperative Day 1. Median length of stay was 3 days. Median follow-up was 21 months. One patient required a redo antireflux procedure 8 months later for persistent dysphagia. Thus laparoscopic revision Nissen fundoplication after a prior open antireflux procedure is feasible and safe.

The repair of inguinal hernia and hydrocele is one of the most common operations in a pediatric surgery practice. This work reviews current concepts in the management of the inguinal hernia and hydrocele. The authors describe current concepts of anesthetic management of children undergoing repair of inguinal hernia. The authors also discuss current management of the contralateral hernia, hernias in premature infants, and the management of an incarcerated hernia. In addition, the authors discuss the role of laparoscopy in the surgical treatment of an inguinal hernia and its application for investigation of the contralateral inguinal canal.

Background/Purpose The purpose of this study was to investigate the rates of vocal cord paresis/paralysis (VCP) in patients treated for esophageal atresia (EA) with and without fistula performed thoracoscopically versus open. Methods A retrospective review of EA cases performed from 2008 to 2014 in an integrated health care system was performed. Results A total of 31 cases of EA were performed by 6 surgeons at 4 different institutions. Seventeen cases were performed thoracoscopically, whereas 14 cases were performed open. In the thoracoscopic group, the average gestational age (weeks) of the patient was significantly higher 38.3 vs. 35.2 ( p =0.016) as well as the average birth weight (grams) 2843 vs. 2079 (p=0.005). There was no difference in the postoperative length of stay, rates of anastomotic stricture, leak, or tracheomalacia. There were 10 cases of vocal cord paresis, 9 from the thoracoscopic group and one from the open group ( p =0.007). Of the 10 cases of VCP, 6 were unilateral (left sided) and 4 were bilateral. Of the 10 cases, 6 resolved, 2 resulted in permanent paralysis, and 2 are currently still being evaluated. Conclusions Thoracoscopic repair of EA appears to have higher rates of VCP. The results are thought to be from thoracoscopic dissection of the esophagus high into the thoracic inlet.

Approximately 77,800 annual lawnmower-related injuries are treated in the USA, with 9,300 involving children. This work reviews the literature and reports our 10-year experience with lawnmower injuries. We retrospectively reviewed patients with lawnmower injuries admitted to the Women and Children's Hospital of Buffalo from 1995 to 2005 and reviewed the literature. Sixteen patients with mower-related injuries were admitted to our institution, with three due to walk-behind mowers and 13 due to riding mowers. The mean age was 7.5 years. Riding mower injuries had a higher average injury severity score (14.3 vs. 9) and a longer average length of hospital stay (15 vs. 2 days). All of the walk-behind mower injuries were extremity injuries, with two requiring amputations. Eleven of the riding mower injuries had extremity injuries alone, one had isolated torso injuries, and one had both extremity and torso injuries. Three required amputations, and the two patients with torso injuries required extensive surgical reconstructions. Pediatric lawnmower injuries, particularly due to riding mowers, are a highly preventable cause of morbidity and mortality. Increased public safety awareness and further manufacturer safety modifications should be strongly encouraged in order to limit this cause of pediatric trauma.

Background: The end result of leakage of pancreatic juice into the peripancreatic space can be sterile necrosis, infected necrosis, or rupture into an adjacent hollow viscus or blood vessel (eg, colon, small bowel, or pseudoaneurysm). If a pancreatic duct (PD) leak is present, should treatment be aimed at minimizing the sequela of the leakage of pancreatic juice and not just supportive observation until a necrosectomy is required? Methods: In 144 patients with severe pancreatitis we investigated whether the presence of a PD leak was associated with necrosis and also asked if PD leak might predict other outcomes such as a length of stay (LOS), mortality, and need for surgery. Furthermore, we questioned whether the use of endoscopic retrograde cholangiopancreatography (ERCP) to search for a PD leak might worsen the clinical outcome because of the potential for introducing microorganisms into an undrained space or exacerbating pancreatitis. Results: The presence of a demonstrable pancreatic duct leak was observed in 37% of patients and was significantly associated with both a higher incidence of necrosis and prolonged LOS (≥20 days). These patients were 3.4 times more likely to have necrosis and 2.6 times more likely to have a prolonged LOS. When treated with a combination of percutaneous drains, pancreatic duct stents, and surgery as necessary, a PD leak (even with its higher necrosis rate) was not significantly correlated with either mortality or the need for necrosectomy. The use of ERCP was not associated with LOS, mortality, or the need for necrosectomy, provided discovered PD leaks were immediately drained. Conclusions: A PD leak is common in patients with pancreatic necrosis but it is also important to locate and decompress in order to impede progression of the disease and keep mortality low.

Background Transinguinal laparoscopy offers a safe and effective method for evaluating the contralateral groin during unilateral inguinal hernia repair (UIHR). The purpose of this study is to determine whether laparoscopic contralateral groin exploration (LCGE) is cost effective. Methods A retrospective review of all children who underwent UIHR and LCGE from 2006 to 2007 by a single surgeon was performed. Cost analysis comparing the time to perform the LCGE and time to repair the contralateral patent processus vaginalis (CPPV) to the cost saved by preventing future operation for a contralateral inguinal hernia repair was calculated based on Medicare reimbursement. Results Eighty-one patients underwent UIHR with planned LCGE; 78 (96.3%) had successful LCGE; 8 (10.3%) had a CPPV and underwent contralateral open repair. The total cost for the additional time to perform LCGE and repair of the 8 CPPV was $13 080. The total cost for returning for a second operation to repair the contralateral inguinal hernia was $20 440. Conclusion Laparoscopic contralateral groin exploration at the time of unilateral inguinal hernia repair was cost effective.

Foreign body-induced appendicitis is a rare but well-known entity. This condition was discovered during the first appendectomy performed almost 275 years ago. For the pediatric surgeon, evaluation of a patient for swallowed foreign bodies is common, and most foreign bodies traverse the gastrointestinal tract without incident. However, when the foreign body becomes incarcerated in the appendix, a prophylactic appendectomy is recommended to prevent appendicitis. We present the case of an asymptomatic 3-year-old boy with a metallic foreign body lodged in the appendix that was treated with a fluoroscopically assisted laparoscopic appendectomy and discuss treatment of sharp vs blunt foreign bodies of the appendix.

The spleen arises from a mesenchymal bulge at the 6-mm stage of development. There are a wide variety of splenic anomalies and variations that range from benign to clinically significant, and this article presents a brief review of splenic embryology and a case report of an anomalous splenic vein that precluded the formation of a Nissen fundoplication.

The continually rising incidence of soft tissue abscesses in children has prompted us to seek an alternative to the traditional open incision and drainage (ID) that would minimize the pain associated with packing during dressing changes and eliminate the need for home nursing care.A retrospective review of all patients with soft tissue abscesses from November 2007 to June 2008 was conducted after institutional review board approval. Patients who were treated with open ID were compared to those treated with placement of subcutaneous drains through the abscess cavities. Both groups received equivalent antibiotic treatment, and all patients were followed in outpatient clinics until infection resolved. The demographics, presenting temperature, culture results, and outcomes were compared between these 2 groups.A total of 219 patients were identified; 134 of them underwent open ID, whereas 85 were treated with subcutaneous drains. The demographics, anatomical location of the abscesses, and bacteriology were comparable between the 2 groups. There were equal number of patients in each group who presented with fever initially. Of those treated with open ID, 4 had metachronous recurring abscesses within the same anatomical region and 1 patient required an additional procedure because of incomplete drainage. There were no recurrences or incomplete drainages in the subcutaneous drain group. The cosmetic appearance of the healed wound from subcutaneous drain placement during the immediate follow-up period is better than that of an open ID.Placement of a subcutaneous drain for community-acquired soft tissue abscesses in children is a safe and equally effective alternative to the traditional ID.

Antegrade enemas administered through a percutaneously placed Chait Trapdoor cecostomy catheter have resulted in a marked improvement in compliance and outcome of patients with fecal incontinence. The percutaneous technique, however, is a two-step procedure that is not performed under direct vision. This report presents the results and lessons learned from our experience with the laparoscopic approach to placement of Chait cecostomy catheters.Retrospective review of patients who underwent laparoscopic placement of Chait cecostomy catheters from 1999 to 2008. Data collected included patient demographics, primary diagnosis, hospital stay, complications, follow-up duration and outcome.Seventeen patients, mean age 11.8 + or - 4.2 years (range 5-17), underwent laparoscopic Chait cecostomy catheter placement over a period of 8 years. Median follow-up was 46 + or - 21 months (range 4-67). The primary diagnosis was spina bifida in 82% of patients. There was one intraoperative complication, which consisted of tangential needle placement into the cecum, and required conversion to an open procedure. Mean hospital stay was 3.8 + or - 1.5 days (range 2-7). Emergency department visits related to Chait catheter complications were mainly due to catheter dislodgement and breakage. Long-term complications included accidental dislodgement of the catheter in seven patients (41%), mechanical failure of the catheter (breaks/leaks) in six patients (35%), hypertrophic granulation tissue in six patients (35%), wound infections at the catheter site in three patients (18%), complications related to the use of fasteners in two patients (12%) and ventirculoperitoneal (VP) shunt infection in two patients (11.8%).The laparoscopic approach to Chait cecostomy catheter placement is a simple and effective procedure. The rate of long term complications such as catheter dislodgement and mechanical failure, which are responsible for the majority of unplanned ED visits, may be decreased by routine yearly catheter exchanges. VP shunt infections are the most serious complications in this patient population consisting mostly of patients with spina bifida.

Surgical management of diseases of the esophagus can be challenging for the pediatric surgeon. Successful management of esophageal problems requires knowledge of cervical, thoracic, and abdominal anatomy. In addition, the surgeon must be aware of functional abnormalities of the esophagus and stomach. Knowledge of potential complications due to technical problems and associated anomalies will allow the pediatric surgeon to anticipate and avoid these problems. In the following chapter, complications related to the treatment of esophageal atresia (EA), gastroesophageal reflux disease (GERD), and esophageal replacement will be presented.

Congenital rectal duplication cyst is a rare entity treated with surgical excision. Without treatment, a rectal duplication cyst may cause a variety of complications, most notably, transforming into a malignancy. We report on a 7-week-old girl who was found to have a rectal duplication cyst. The rectal duplication cyst was successfully excised laparoscopically. Rectal duplication cysts are rare alimentary tract anomalies generally discovered during childhood. Complications include symptoms arising from the cyst and the possibility of malignant degeneration. They are typically managed by surgical excision.

A method of providing asymmetric feedback in the triangular ring laser structure was devised through the simple alterations of the waveguide shape. Two kinds of alterations were designed and implemented, one being the “optical diode,” the other being the tapered waveguide. Unidirectional operation was achieved for the ring lasers, with a single-beam slope efficiency of 0.23 W/A, which was the highest single-beam slope efficiency reported for semiconductor ring lasers.

Laparoscopic pyloromyotomy (LPM) for the treatment of infantile hypertrophic pyloric stenosis (HPS) has gained popularity in recent years. This study examines the learning curve associated with LPM.We performed a retrospective analysis of patients undergoing LPM at a children's hospital between January 1, 1997 and June 30, 2003. Data including age, weight, complications, operative time, time to feeding, and length of postoperative stay were analyzed using the Student's ttest.A total of 51 patients underwent LPM during the study period. Patient characteristics were similar throughout the study period. Operative time ranged from 12 to 55 minutes (mean, 25 minutes). Mean operative time decreased significantly from 31+/-11 minutes for the first 15 patients, to 25+/-6 minutes for the second 15 patients, to 20+/-7 minutes for the last 15 patients (P0.05). Operative times were erratic for the early cases but became more consistent over time, especially after 30 cases. Conversion to an open procedure was required in two patients. Complications included an umbilical port site wound dehiscence and readmission for persistent vomiting. There were no mucosal perforations. Time to ad lib feeding and postoperative length of stay did not change over time.LPM has a steep learning curve, especially for the first 15 patients. Operative time decreases and becomes more consistent after about 30 cases. Despite the learning curve, LPM can be performed safely and effectively without an increase in complications.

Fraternal twins with identical left-sided foramen of Morgagni hernias are described. The occurrence of this rare type of congenital diaphragmatic hernia in twins suggests that genetic factors play a role in the formation of this lesion.

Ramstedt pyloromyotomy through a right upper quadrant (RUQ) transverse incision has been the traditional treatment for hypertrophic pyloric stenosis. Recently, laparoscopic (LAP) and circumumbilical (UMB) approaches have been introduced as alternative methods to improve cosmesis, but concerns about greater operative times, costs, and complications remain. This study compares the three operative techniques and examines their advantages and complication rates.We performed a retrospective review of patients undergoing pyloromyotomy at a children's hospital between January 1997 and June 2003.Two hundred ninety patients underwent pyloromyotomy by LAP (n = 51), RUQ (n = 190), or UMB (n = 49). Complication rate, time to ad libitum feeding, incidence of emesis, and postoperative length of stay did not differ considerably among groups. Two LAP patients were converted to RUQ. Mucosal perforation occurred in three patients each in the RUQ and UMB groups, but none in the LAP group. Operative times were considerably less for LAP (25 +/- 9 minutes) than for RUQ (32 +/- 9 minutes) and UMB (42 +/- 12 minutes) (p0.05, ANOVA, Bonferroni). Charges related to operations and anesthesia were considerably greater for UMB (operation: US 1,574 dollars +/- US 433 dollars; anesthesia: US 731 dollars +/- US 190 dollars) compared with the other two groups (p0.05, ANOVA, Bonferroni), but did not differ between LAP (operation: US 1,299 dollars +/- US 311 dollars; anesthesia: US 586 dollars +/- US 137 dollars) and RUQ (operation: US 1,237 dollars +/- US 411 dollars; anesthesia: US 578 dollars +/- US 167 dollars). Data are presented as mean +/- SD.Advantages of LAP include a shorter mean operative time without higher complications or costs. UMB is associated with the greatest mean operative time and costs. Laparoscopic pyloromyotomy is a safe and effective approach to the treatment of hypertrophic pyloric stenosis.

A 10-year–old boy with cystic fibrosis (CF) (ΔF508/G551D mutation) underwent an uneventful elective interval laparoscopic appendectomy. During routine laparoscopic inspection of the abdomen and groins, congenital bilateral absence of the vas deferens was noted. Pictures of the patient's internal inguinal ring noted at time of laparoscopy are presented and compared with a similar-aged patient's internal ring with a normal vas deferens. The genetics of CF patients associated with congenital bilateral absence of the vas deferens is reviewed. The pediatric or general surgeon performing a herniorrhaphy should be aware of this anomaly in CF patients.

Waveguide diode ring lasers (WDRL) in a triangular geometry exhibit a unique combination of characteristics including low-noise, medium power output, small size, good efficiency and low cost integrability and manufacturability which make them attractive candidates for analog optical links requiring large dynamic range and bandwidth. We show that 10 - 20 mw low noise (< -150 dBm) lasers appear feasible which provide low cost manufacturability and integrability. With integrated small amplifiers 85 mW single mode output has been shown. Because these WDRLs operate with unidirectional traveling waves in entirely single mode waveguide and contain a natural output coupler, they show a combination of attractive features not found in other lasers.© (1996) COPYRIGHT SPIE--The International Society for Optical Engineering. Downloading of the abstract is permitted for personal use only.

Mucinous cystadenomas of the pancreas are uncommon lesions in adults and even more rare in children. This report presents a case of a pancreatic mucinous cystadenoma in a 1-year-old boy and offers a review of the literature and discussion of the surgical implications.