IPEG 2001 ORAL ABSTRACTS
s01. Paediatric Failure to Thrive and Anemia
Caused by an Intrathoracic Stomach
Marc A. Levitt M.D., Colin J. Powers M.D., Guy F. Brisseau M.D.
Department of Paediatric Surgery, Children's Hospital of Buffalo,
State
University of New York at Buffalo, Buffalo, New York, USA
Failure to thrive in the paediatric age group has a long differential
diagnosis most of which do not require surgery.
We report a 23 month old child who presented with failure to thrive.
Investigations demonstrated an iron-deficient anemia and a chest X-ray
revealed a mediastinal mass. This mass appeared to be the stomach
on subsequent investigations. The location of the gastro-esophageal
junction (G-E junction) could not be demonstrated.
Laparoscopic reduction of the intrathoracic stomach verified that
this was a paraesophageal hiatal hernia with an intraabdominal G-E
junction. Repair was completed laparoscopically with closure of the
crua and a 360 degree fundoplication. The G-E junction and the pylorus
were closely approximated and a primary G-Tube button was placed to
prevent gastric volvulus. The patient began to gain weight post-operatively
and continues to do so. The G-Tube was not required for feeding and
was removed 6 weeks post operatively.
Paraesophageal hernias not associated with previous fundoplication
in children are very unusual. This case demonstrates the utility of
laparoscopy in both diagnosis and treatment of this uncommon paediatric
cause of failure to thrive.
s02. LAPAROSCOPIC FUNDOPLICATION: MEDIUM- TERM
OUTCOME.
Henri Steyaert,MD, Elizabeth Trevino, MD, Myriam Chami,MD, Nathalie
Bosson,MD, Anne Geoffray, MD, Jean-Stéphane Valla, MD. Pediatric
surgery and pediatric radiology Fondation Lenval Nice, France.
Aims : To determine medium term outcome of laparoscopic Nissen and
Toupet fundoplication for gastro-oesophageal reflux disease in terms
of recurrence, growth, dysphagia, and satisfaction.
Methods: Review of all patients having had a laparoscopic fundoplication
before 06/98 at our institution to allow for a minimum of two years
follow-up. Patients were invited to an evaluation and a barium meal
was carried out.
Results: A total of 53 fundoplications were performed ( 25 Nissen
, 27 Toupet and 1 Dorr procedures) before 06/98. Minimum 2 years follow-up
was obtained in 44 patients (84%).
34 % were neurological patients; one of them died soon after the
operation. A barium meal was obtained in all except 2 patients. 3
procedures were converted. Since initial procedures 2 patients required
reoperation (timing and indication are discussed). 98% of patients
have nor or only mild heartburn, 98% have no or mild dysphagia.One
patient suffers from dumping syndrome. Growth and weight gain was
normal in all patients. 1 patient is back on regular anti-reflux medication.
Reoperation is mandatory.
Conclusion: Laparoscopic fundoplication in children offers excellent
medium-term symptom control with minimal complications. Results in
neurologically impaired patients are also excellent. Results seem
better than in open surgery and offer the classical advantages of
the laparoscopic approach.
s03. IS LAPAROSCOPIC FUNDOLPLICATION MORE DIFFICULT
IN INFANTS?
James Hamill MBCHB, Kiki Maoate MBChB, Spencer Beasley MS. Department
of Paediatric Surgery, Christchurch Hospital, New Zealand.
Because laparoscopic fundoplication (LF) is perceived to be a greater
technical challenge in infants, we reviewed objective evidence of
difficulty (operative time, hospital stay and complications) to compare
infants and older children who had undergone LF.
Methods: Children who had undergone LF between 1/11/1996 and 31/10/2000
were identified using an audit database. Operative times were obtained
from the operating suite database and case noted were reviewed. Patients
ere grouped according to weight at operation: group A, less than 10kg;
group B, 10 kg or more.
Results: Over the 4-year period, 63 children underwent LF, 17 in
group a and 46 in group B. The median weight at operation was 7.5
kg (range 4.2-9.3 kg) in group A and 16.8 kg (range 10.3-50 kg) in
group B. The median operative time was 87 minutes in group A (range
52-235 minutes) and 105 minutes in group B ( range 58-185 minutes),
p=0.10. The median postoperative hospital stay was 5 days in group
A and 3 days in group B, p=0.13. The complication rate was 29% in
group A and 22% in group B, p=0.52.
Conclusions: Laparoscopic fundoplication in infants (<10kg) is
not associated with any significant difference in operative time,
hospital stay or complications when compared with laparocopic fundoplication
Iarger children >10 kg.
s04. THE SAFETY AND EFFICACY OF LAPAROSCOPIC
NISSEN FUNDOPLICATION IN EARLY INFANCY
José L. Iglesias, MD, Kelly Kogut, MD, Elizabeth Owens,
MD, Steve Rothenberg, MD, Kurt Schropp, MD, Keith Georgeson, Thom
Lobe. MD. LeBonheur
Children's Hospital, Memphis, TN, University of Alabama, Birmingham,
AL, Rocky Mountain Pediatric Surgery, Denver, CO.
Purpose: Life threatening complications of gastroesophageal reflux
(GER), including apnea, aspiration, and failure to thrive which are
unresponsive to medical management, sometimes mandate surgical intervention
in the very young. The aim of this study is to evaluate whether laparoscopic
Nissen fundoplication in babies less than 3 months of age is safe
and effective.
Methods: The medical records of all patients less than 3 months
of age or less than 3.5 kg at the time of laparoscopic Nissen fundoplication
performed from 2/98 - 3/00, at three institutions were reviewed. The
short-gastric vessels were routinely divided, and the crura were reapproximated.
Short, floppy, 3600 wraps were fashioned over a Bougie (22-30F) with
2-4 sutures incorporating the anterior esophagus.
Results:
Mean age=68 days Mean operative time=60 min Mean time to discharge
< 10 days
Mean Weight=3.lkg Mean time to full feeds=3 days Mean follow-up >150
days
Gastrostomy= 82/104 patients
There were 11 complications related to: laparoscopy (4), gastrostomy
(4), patient selection (1), and fundoplication (2). One infant with
a malpositioned G-tube still has occasional emesis; all others have
no clinical evidence of GER. There was one death in an infant with
trisomy 18 and a G-tube leak.
Conclusions: Infants undergoing laparoscopic fundoplication in early
infancy feed earlier and spend less time in the hospital than those
reported in the literature undergoing the open approach. Most of the
complications are due to technical errors and can be avoided with
meticulous attention to detail. Overall, laparoscopic fundoplication
appears to be safe and effective in small infants.
s05. EVALUATING CANDIDATES FOR PERCUTANEOUS
ENDOSCOPIC GASTROSTOMY
John Lawrence, MD, Department of Surgery - The University of New
Mexico Hospital - Albuquerque, New Mexico, USA
Controversy exists regarding the evaluation and selection of appropriate
candidates for percutaneous endoscopic gastrostomy (PEG) tube placement.
The purpose of this study was to review the author's experience regarding
pre-operative evaluation and outcome for patients undergoing PEG tube
placement.
From August 1997 to August 2000 38 patients were selected to undergo
PEG tube placement. The patients ranged in age from 1 month to 20
years (median 18.1 months). The diagnoses leading to referral for
PEG included sever neurological impairment (14), cystic fibrosis (7),
prematurity with failure to thrive (7), metabolic disorders (4), and
S/P trauma (3). All patients underwent an upper GI. For patients without
significant reflux seen on upper GI, and without history indicative
of severe reflux, and intragastric feeding tube was placed and bolus
feeds were given for 24 hours. If no evidence of emesis or aspiration
was observed, PEG was performed without further testing.
All PEG tubes were placed in the operating room. There were no intraoperative
complications. There was one major postoperative complication, a wound
infection in a diabetic requiring a 10-day post-procedure hospital
stay. With a mean follow-up of 18 months only 2 of 38 patients required
a conversion to a fundoplication for reflux which could not be controlled
medically.
PEG tube placement can be safely performed in a medically fragile
patient population with a low risk of complications and a low rate
of conversion to Fundoplication. Selection for PEG tube placement
can be performed without resorting to ph probes or nuclear medicine
scans in many patients.
s06. LAPAROSCOPIC PLACEMENT OF A LOW-PROFILE
GASTROSTOMY TUBE PLACEMENT
Hanmin Lee, M.D., Angela Jones, B.A., Sanjeev A. Vasudevan,B.A.,
and Mark L. Wulkan, M.D., Department of Surgery, University of California
at San Francisco, San Francisco, CA (HL) and Department of Surgery,
Emory University , Atlanta, GA (AJ, SAV, MLW)
Purpose: To evaluate the safety, efficacy, and cost of laparoscopic
placement of a low profile gastrostomy tube (LAPGT).
Methods: The medical records of all patients who underwent laparoscopic
gastrostomy tube placement (n=51) either alone (n=8) or in conjunction
with a fundoplication (n=43) over a 2 year period (1988-1999) were
evaluated for complications, length of procedure and cost. Costs were
compared to 8 randomly selected patients who underwent percutaneous
endoscopic gastrostomy (PEG) over the same period.
Results: There were no major complications related to gastrostomy
tube placement in any of the 51 patients who underwent LAPGT. Mean
length of operative time in the 8 patients who underwent LAPGT alone
was 45 minutes. The initial cost for placement of a LAPGT was $1050
more than for placement of a PEG. The cost difference was related
to operative time. However, 12% of all patients during this time who
underwent PEG required a second operation for revision of the PEG
to a low-profile device.
Conclusion: LAPGT is a safe alternative to other methods of gastrostomy
tube placement. Initial cost of LAPGT is slightly higher than for
PEG based on operative time. However, further analysis is needed to
compare overall costs based on need for reoperation and treatment
of complciations.
s07. GASTROSTOMY BY ENDOSCOPY OR BY LAPAROSCOPY:
HARD LEARNED LESSONS.
Henri Steyaert,MD, Bruno Descos&,MD,Jean-Stéphane Valla,MD.
PEDIATRIC SURGERY and PEDIATRIC GASTROENTEROLOGY (&) FONDATION
LENVAL, Nice, France.
Purpose : The aim of this study was to compare prospectively the
results of the percutaneous endoscopic (PE) and the laparoscopic (LAP)
technique for tube gastrostomy (TG) with secondary button placement.
Methods: All our gastrostomies between 1995 and 2000 were prospectively
divided in 2 groups. Children who presented GER were treated by laparoscopy
for antireflux surgery and gastrostomy. Other children were treated
by the PE technique. The authors looked for correlation between type
of technique and encountered complications.
Results: TG was performed by PE in 19 cases and by LAP in 14.Overall
complication rate was high (45,5%) with 47% for PE and 43% for LAP.
In the PE group 21% of the complications appeared during secondary
button placement for only 7% after LAP. Complication rate decreased
with the years only in the PE group (12,5% > 99).The most serious
complications were ileal perforation and button placement outside
of the stomach.
Conclusion: LAP or PE operations for TG may raise a lot of complications.
Mishaps can also occur at the time of conversation from initial TG
to button. By PE insufflation of the stomach must be maximum. Sterility
is important but difficult to realise effectively. TG removal must
be done carrefully and button placement must be controlled by an opacification
if placement was not easy. Primary button gastrostomy placement by
LAP precludes perhaps many of the complications associated with the
other techniques.
s08. COMPLICATIONS OF MONOCHORIONIC TWINNING:
SPECTRUM OF DISORDERS AND TREATMENT
CRAIG ALBANESE, MD, ROMAN SYDORAK, MD, HANMIN LEE, MD, VICKIE FELDSTEIN,
MD, GEOFFREY MACHIN, MD, KUOJEN TSAO MD, DIANA FARMER MD, MICHAEL
HARRISON MD
Departments of Surgery and Radiology, Fetal Treatment Center,University
of California, San Francisco, Department of Pathology, Kaiser Permanente
Medical Center, Oakland, Califonia
In monochorionic twin pregnancy, fetuses share one placenta and
often have intertwin vascular connections. Anatomical/physiological
abnormalities can threaten 1 or 2 twins. We present several minimal
access treatments designed to produce 2 or at least 1 intact survivor.
From 1998 to 2000, we sonographically evaluated 60 twin pregnancies:
twin-to-twin transfusion(30), twin reversed arterial perfusion(10),
discordant growth(4), discordant anomaly(9), conjoined twins(3), other
(4).
Ultrasound-guided intervention was performed for TTTS refractory
to amnioreduction, for select TRAP sequences, and for select twins
discordant for an anomaly. Fetoscopy was used when laser ablation
of abnormal placental vascular connections was deemed necessary. Fifteen
TTTS cases underwent laser ablation alone of abnormal choraniopagus
(64% survival); 2 underwent cord ablation as well. 5 with TRAP sequence
had radiofrequency ablation of the cord of the acephalic/acardiac
cotwin (100% success). 5 twins discordant for an anomaly underwent
laser ablation of communicating vessels and umbilical cord transection
(100% success).In all but 2 cases the procedures were performed percutaneously.
Procedures were well tolerated; mean age at delivery=33 weeks. All
infants are neurologically intact. A normal monochorionic twin threatened
by an anomalous cotwin or a set of twins threatened by abnormal placental
vascular connections can be successfully salvaged using a variety
of minimal access techniques.
s09. LAPAROSCOPIC DUODENO-JEJUNOSTOMY FOR PROXIMAL
JEJUNAL ATRESIA IN A NEWBORN INFANT
CK Yeung, MD. YH Tam, WG Manson, KH Lee, Division of Paediatric
Surgery, Department of Surgery, Chinese University of Hong Kong, Prince
of Wales Hospital, Hong Kong, China
Laparoscopic reconstructive surgery in newborn infants poses particular
challenge to the pediatric surgeon because of difficulties in intracorporeal
dissection and suturing in a very small working space.
Objective: We herein report a case of laparoscopic duodeno-jejunostomy
for proximal jejunal atresia in a newborn infant.
Patient and Method: The patient was a male infant born at full
term with a birth weight of 2.76kg. Antenatal ultrasound detected
the "double-bubble" sign suggestive of duodenal atresia.
Postnatal abdominal X-ray showed a dilated gastric and duodenal shadow
with the absence of distal bowel gas. Operation was performed on the
second day of life. A 5mm port via an infraumbilical incision was
used for the telescope. Three other 3mm working ports were also inserted.
Laparoscopic findings revealed Type 1 jejunal atresia just distal
to the duodeno-jejunal flexure. The transverse colon was hitched up
by transabdominal stay sutures. The grossly dilated duodenum and the
collapsed jejunum just distal to the atretic segment were also hitched
up. A side-to-side duodeno-jejunostomy was fashioned laparoscopically
using 5 zero polyglactin suture.
Results: The laparoscopic procedure was completed in 150 minutes.
Enteral feeding was started on day 7 postoperatively. There were no
procedure-related complications. The baby had been thriving without
any symptoms after a follow-up of 5 months.
Conclusions: With good pre-operative planning, advanced laparoscopic
reconstructive surgery such as bowel anastomosis can be safely and
successfully performed in neonates.
s10. COMPUTER-ASSISTED THORACOSCOPIC REPAIR OF
ESOPHAGEAL ATRESIA WITH DISTAL TRACHEOESOPHAGEAL FISTULA
CK Yeung1, MD, TE Lobe2 MD,BS, YH Tam1, KH Lee1 Division of Paediatric
Surgery1, Department of Surgery, The Chinese University of Hong Kong,
Prince of Wales Hospital, Hong Kong, China; and Le Bonheur Children's
Medical Center2, University of Tennessee-Memphis, Memphis, USA.
Repair of esophageal atresia (EA) with distal tracheoesophageal
fistula (TEF) through a right open thoracotomy has remained the treatment
of choice over the past few decades. With the advent of minimally
invasive surgical techniques, a thoracoscopic approach is feasible
although the small pleural space in a newborn infant still poses a
technical problem. The application of a voice-controlled robotic arm
in the manipulation of the telescope offers significant advantage
by providing a stable endoscopic view with no tremor or fatigue that
is inevitable of a human assistant.
Objective: We herein report a case of thoracoscopic repair of esophageal
atresia in a newborn infant using a computer-assisted endoscopic system
with a voice-controlled robotic arm.
Patient and Method: A full-term female infant was found to have
esophageal atresia with a distal tracheoesophageal fistula on Day
1. Echocardiogram showed a normal left-sided aortic arch and a patent
ductus arteriosus. Operation was performed at 6 hours after birth.
A 3F Fogarty catheter was first placed in the right main bronchus
for controlled single-lung ventilation. The patient was placed in
a semiprone position with the right side elevated for about 6Oº.
A 5mm port was placed in the fourth intercostal space at the mid-axillary
line for the 3Oº telescope. Another 5 mm and one 3 mm working
ports were placed at the anterior axillary line above and below the
nipple level. An Aesop-Hermes Ready System fitted with a voice-controlled
robotic arm was employed to control the telescope. A transpleural
approach was used with CO2 insufflation to compress the lung. The
pleura was incised posterior to the vagus nerve, and the azygous vein
was coagulated and divided. The upper pouch was identified and freed,
and the distal TEF was divided and closed with 5mm metal clips. Primary
end-to-end esophageal anastomosis was completed using interrupted
4 zero polydioxanone sutures over a Replogle tube.
Results: The procedure was completed in 175 minutes. Postoperatively
lung expansion was satisfactory and recovery was uneventful. Enteral
feeding was started on day 4. A contrast esophagogram confirmed an
intact anastomosis with good calibre. There was no procedure related
complication.
Conclusions: Thoracoscopic repair of OA with distal TEF could be
safely and effectively performed using modern endoscopic surgical
techniques. The use of a voice-controlled endoscopic system greatly
facilitated the procedure by providing a stable endoscopic view in
a very confined space and with minimal bodily interference between
the surgeon and the assistant.
s11. DIAFRAGMATIC CONDITIONS IN INFANTS AND CHILDREN:
ENDOSURGERY REPAIR PERSPECTIVES
Francisco J. Berchi M.D., H. Allal M.D., I.Cano M.D., M.I. Benavent
M.D., E. Portela M.D., A.Garcia M.D., Pediatric Surgery Department,
HUMI, Hospital 12 de Octubre, University Complutense, Madrid/Spain
Introduction: The diaphragm, can be approached either by the thoracic
or abdominal way.
Methods and Procedures: The thoracoscopic approach has been discribed
for the diagnosis and treatment of right sided diafragmatic disorders.
Congenital diafragmatic hernia often presents as a neonatal emergency
with respiratory distress due to lung hypoplasia. Blood gas sampling
is mandatory.X-ray of the thorax demonstrated the existance of diafragmatic
hernia.
Results: Our experience is: Within 11 cases we were able to close
the defect laparoscopically in 10 children and 1 thoracoscopically.In
10 we closed the deffect without use of a patch.In 1 child with a
retrosternal hernia(Morgagni)has been reproduced and needed a new
laparoscopic repair. 1 patient with right sided defect had a good
laparoscopic outcome. 4 with left sided defect of which two needed
a primary laparoscopic repair without complications. In 2 cases with
Bochdalek hernias left sided, in age from 1 day, we had complications:
in 1 newborn primary thoracoscopically appeared a lot of technique
problems as well as laparoscopically and finally he needed laparotomic
repair. Another one couldn't be operated laparoscopically because
the visibility was very bad, but laparotomic convertion has been satisfactory.
Conclusion: The coelioscopic method provides excellent intra-abdominal
views, short operation time, simple handling, short hospitalization
time and good cosmetic results.
s12. THORACOSCOPIC AORTOPERICARDIOSTERNOPEXY,
AN EFFECTIVE TREATMENT FOR LIFE-THREATENING TRACHEOMALACIA
Klaus Schaarschmidt MD, Andreas Kolberg-Schwerdt MD, Klaus Bunke
MD, Centre Of Pediatric Surgery / Pediatric Anesthesiology Berlin-buch,
Germany
Objective: Severe tracheomalacia, i.e more than 90% tracheal stenosis,
is frequently associated with esophageal atresia. Thoracoscopic aortopexy
has been reported for an infant this year. We report a modified technique
in the dramatic case of a 4 -year-old boy born with Vacterl association,
who suffered since birth from constant stridor, frequent respiratory
pauses, severe cyanosis during feeds and 8 cardiac arrests. Bronchoscopy
showed total collapse of a 6 cm tracheal segment.
Methods and Procedures: From three 5 mm left thoracic accesses,
the thymus was mobilized and the ascending aorta freed completely.
Three rows of longitudinal adventitial 3/0 or 2/0 (according to the
child's age) prolene sutures were placed on the aortic arch and proximal
pericardium, the right suture including the anonymous artery. Bronchoscopy
shows which direction of traction on the threads results in the maximal
tracheal lumen and where the threads should pass through the sternum.
Results: The moribound child improved dramatically in the past 6
months, bronchopulmonary symptoms disappeared, he gained weight and
bronchoscopy demonstrated a widely patent trachea. Oxigen suturations
improved from about 84-89% to well above 96%.
Conclusion: Our technique of thoracoscopic aortopericardiosternopexy
is feasible and effective even in high-risk children and the most
the severe forms of tracheomalcia.
s13. COMPARISON OF PHYSIOLOGICAL CHANGES AND
EFFICACY OF LAPAROSCOPIC AND OPEN
PYLOROMYOTOMIES
Gordon MacKinlay, FRCS, Benjamin Aldridge, The Royal Hospital for
Sick Children, Edinburgh, Scotland.
Objective: An analysis of physiological changes and outcome measures
in laparoscopic pyloromyotomies (LPM) compared with open pyloromyotomies
(OPM) during an 18-month period at the Royal Hospital for Sick Children,
Edinburgh.
Methods: From January 1999 to June 2000 forty-eight patients had
surgery for pyloric stenosis (20 laparoscopic and 28 open). Duration
of operation, complications, rate of recovery, analgesic requirement,
temperature change, ETCO2, heart rate and blood pressure were examined
and compared.
Results: There was no significant difference in the duration of
surgery or in the complication rate. Average duration of operation
for LPMs was 32.20mm and for OPM5 33.86mm. The rate of recovery was
significantly faster and the analgesic requirement lower for the infants
undergoing the laparoscopic pyloromyotomies. Average time from operation
to discharge for LPM5 was 41 .9 hrs whereas for OPMs it was 57.29
hrs. Average analgesic requirement for LPMs was 2.06 doses of paracetamol,
whereas the OPMs required 3.61 doses. The temperature change, heart
rate and blood pressure were not significantly different. As might
be expected there was a statistically significant increase in the
ETCO2 in the laparoscopic procedures, although none of the ETCO2 values
rose above 6kPa.
Conclusions: Laparoscopic pyloromyotomies have no significant adverse
physiological effects, are no slower to perform, have a faster recovery
time, less morbidity and better cosmetic results.
s14. COMPARISON OF 72 SUCCESSFUL LAPAROSCOPIC
PYLOROMYOTOMY WITH OPEN PROCEDURE FOR CONGENITAL HYPERTROPHIC PYLORIC
STENOSIS
Qinming Zhang, MD. PhD. Yongwei Chen, MD. Dawei Hou, MD. Department
of Neonatal Surgery, Beijing Children's Hospital, Beijing, P.R CHINA
Purpose: To clarify the advantage of laparoscopic procedure and
provide basis in transforming routine open abdomen to laparoscopic
procedure for congenital hypertrophic pyloric stenosis.
Methods: Total 122 patients with congenital hypertrophic pyloric
stenosis were undertaken pyloromyotomy successfully during past three
years. 72 out of them were operated by laparoscope and another 50
were taken by conventional procedure. The average time of operation,
days and total expenses of hospitalization were calculated separately
for comparison of two methods. All the patients of both methods were
followed-up 6 months after discharging for cosmetic abdominal wound
evaluation.
Results: It took 12±1.6 minutes for laparoscopic procedure
showing significant shorter (p<0.01) than conventional one of 24±1.9
minutes. The average days of hospitalization for laparoscopic method
were calculated at 3.3±0.2 with significant different (p<0.01)
of conventional one at 7.5±0.3. There was no significant different
in total expenses between two methods. The abdominal wounds were shown
more cosmetic in laparoscopic method than in conventional one.
Conclusions: Laparoscopic pyloromyotomy is a quick, safe and minimal
invasive procedure, and can be performed as a routine procedure for
congenital hypertrophic pyloric stenosis
s15. LAPAROSCOPIC CLOSURE OF PATENT PROCESSUS
VAGINALIS IN BOYS WITH INGUINAL HERNIA USING AN ENDONEEDLE.
Masao Endo, MD, Etsuji Ukiyama, MD, Urawa Municipal Hospital, Urawa,
Japan
We presented a specially devised suture needle (Endoneedle) for
laparoscopic closure of PPV and its use in girls at the IPEG-2000.
The aim of this paper is to introduce an innovative technique that
we have developed for completely extraperitoneal ligation of the PPV,
sparing the spermatic cord and vessels, in boys with inguinal hernia
by video.
The instruments consist of an Endoneedle, 2-mm coagulator, 2-mm
scissors and 15-G sheath needle. The procedures are performed with
the help of a 5-mm telescope inserted through the umbilicus. Small
incisions are made on the peritoneum by the side of the spermatic
cord and vessels after coagulation with the coagulator inserted through
the 15-G sheath needle run through the internal ring. The peritoneum
is come off the cord and vessels by the scissors at the peritoneal
incision. The Endoneedle is inserted just above the internal inguinal
ring and advanced extra-peritoneally across the cord and vessels.
The internal ring is encircled with a 2-0 non-absorbable suture by
the same technique as for girls. The suture is tied up achieving completely
extraperitoneal ligation of the PPV, leaving the cord and vessels
in retroperitoneal space.
Since February 1999, this procedure has been carried out in 70
boys with inguinal hernia/hydrocele under informed consent. The age
ranged from 3 months to 10 years with a median of 2 years. There has
been no postoperative complication and no recurrent hernia/hydrocele.
The average operative time was 30.5 minutes for unilateral and 34.9
minutes for bilateral closure in recent 20 cases.
The spermatic cord and vessels are spared easily with certainty
by this technique, and the procedure has excellent cosmetic results
leaving no traces of the herniorrhaphy.
s16. EXPERIENCES OF 450 CASES MICRO-LAPAROSCOPIC
HERNIOTOMY IN INFANTS AND CHILDREN
Lee Yuzhou M.D., Department of Pediatric Surgery The First People's
Hospital of Foshan Guangdong, P.R. China.
Aims: To make the micro-laparoscopic herniotomy a well-received
new technique by fellow surgeons and the patients' parents through
experiences drown from 450 cases.
Methods: The puncture trocar was placed in the umbilical fold incision
through which inserted the micro-laparoscope, the operative cramp
was inserted through the paraumbilical incision. After finding the
affected cor endocyclic opening under laparoscope, sutured the medial
and lateral semi-peritoneum using needle holding thread and needle
hook which inserted through the stab hole located in the surface projection
of the affected cor endocyclic with the help of the cramp. While the
former needle sutured , the thread was brought into the peritoneal
cavity, and while the later one sutured, the thread was brought out
, the knot tied up in the stab site subcutaneous, the cor endocyclic
opening was then closed .
Results: As we use micro-lapaloscope and needle-like instruments,
such operation has the advantages of small incisions, minor damage,
easily operation, short operative duration, quickier recovery, no
postoperative scar. There are 4 recurrences out of 450 cases after
5 months to two years following-up during Mar. 1998 to Mar. 2000 ,
the recurrence rate is 0.88%. There are no significant differences
from that of traditional operation method 0.9%.
Conclusion: This is a favorable new technique in treatment to indirect
inguinal hernia in infants and children which is worthy of popularization.
s17. DIRECT INGUINAL HERNIA IN CHILDREN
Clark Gorsler M.D., Felix Schier M.D.; Department of Pediatric
Surgery, University Medical Center Jena, Germany
Objective: Direct inguinal hernia are considered very rare.
In laparoscopy they are seen more frequently than in open surgery.
Methods: The direct hernias were detected during routine laparoscopic
hernia repairs. The age of the children was 18 month, 4, 5, 6, 8 and
12 years.
Results: Direct hernias were found in 4% of patients (7/ 174). All
7 patients were boys and all had the direct hernias on the right side.
Two of the boys had undergone 3 previous open hernia repairs with
subsequent recurrence. One boy had a combination of direct and indirect
hernia (en pantaloon). In one boy a recurrence was noted and later
closed in the open technique.
Conclusion: Direct hernias may go unnoticed in open surgery. They
are not too difficult to close laparoscopically. In case of a recurrence
of open hernia repair we would suggest a laparoscopy.
s18. ERGONOMICS ANALYSIS AND IMPROVING THE ENVIRONMENT
FOR PATIENT AND SURGEONS
Stephen Potts, FRCS; Gordon Dodds; MD, Royal Belfast Hospital For
Sick Children, 180 Falls Road, Belfast, Northern Ireland; Queens University,
Ashby Building, Stranmillis Road, Belfast, Northern Ireland
To analyze force and torque as it effects the laparoscopic surgeon
at the joints of the upper limb during surgery. The information gathered
will assist surgeons to reduce the forces on their own joints by way
of posture alteration, correct selection of instruments and port positioning.
Application for the data will also have a direct input into the design
of surgical instruments for laparoscopy.
A virtual reality mannequin currently in use in industry with fully
verified force / torque analysis systems is used in the project. This
permits accurate calculation of forces and torques on the joints,
change of instruments and positioning of instruments, which alter
these parameters.
Exaggerated shoulder abduction and adduction is a constantly noted
trend in the laparoscopic operator. By contrast this is frequently
accompanied by marked supination of the hands during suturing and
accompanying extreme adduction of the shoulder, which are positions
not adopted during open surgery. The specific force / torque analysis
will be presented.
The ergonomics of operating laparoscopically, as opposed to conventional
open surgery, have significant implications for the surgeon. The planning
of operating setup and the design of instruments need careful attention
if the benefits for laparoscopic surgery passed onto the patient are
not to become a disadvantage for the surgeon.
s19. DESIGNING ALL-IN-ONE TYPE MANIPULATOR FOR
THE ENDOSURGERY
Yasuhide Morikawa,M.D., Toshiharu Furukawa, M.D., Kazuo Nakazawa,Ph.D.,
Masaki Kitajima, M.D., Nobuto Matsuhira, Ph.D., Hideaki Hashimoto,
Ph.D., Makoto JInno, Ph.D.; Department of Surgery and System Design
Engineering,Keio University School of Medicine,Tokyo,Japan Toshiba
Corporation, Corporate R&D Center, Kawasaki, Japan
Robotic surgery to provide 5 to 6 degrees of freedom has launched into
the field of cardiovascular and GI laparoscopic surgery. These manipulators
are designed as a master-slave manipulator which requires high fidelity
and safety. The mechanism of the manipulator is highly complicated in
terms of machinery and electronics. Furthermore, the operator has to
use the apparatus apart from his patient and the whole system may hide
a child from operator's view. We have been working to develop a new
robotic manipulator for laparoscopic surgery to overcome those problems.
The manipulator consists of three parts; effector, holding arm
and controller. The holding arm provides 4 degrees of freedom(x,y,z
and rotation) and the effector gives 3 degrees of freedom(pitching,
yawing and gripper). The surgeon holds the grip of the controller
which has three joints, and the information of any movement is transmitted
to the micro-motor. A tip of the instrument and the axis of the rolling
are set by the operator ,and the effector receives electrical control
from master arm. The cymbal mechanism of the master arm could minimize
interference between positioning and direction.
Although the prototype is now being tested, the system may be practically
suitable for general laparoscopic surgery including pediatric population.
s20. VIRTUAL REALITY TRAINING FOR LAPAROSCOPIC
SURGERY - WHAT DO WE WANT AND WHAT DO WE NEED?
Stephen Potts, FRCS; Royal Belfast Hospital For Sick Children,
180 FaIls Road, Belfast, Northern Ireland
To ascertain the view of surgical trainees as to the requirement
and design of virtual reality models to teach laparoscopic skills.
A simple virtual model of cholecystectomy was created. Trainees were
asked for their view on:
- anatomical design
- image rotation
- image zoom
- control of image distortion
- control of image subtraction / dissection
- two simulated instrumentation versus single mouse
There was no variation between all 10 trainees questioned. The
previous anatomical design was regarded as the least important feature.
The remaining aspects were regarded as essential.
Virtual reality training is seen as an important aspect in familiarising
trainees with basic principles and even the acquisition and maintenance
of skills. The preference for two-hand operating is strongly emphasized
but not essential in the acquisition of facial principle. In addition
the items in the questionnaire, the desire for the completed model
to detect collision.
Note: The prototype virtual reality model will be demonstrated in
the course of the presentation.
s22. LOW NARCOTIC ANALGESIC REQUIREMENTS IN PEDIATRIC
LAPAROSCOPIC SPLENECTOMY
Grant Geissler, M.D.;Valerie Talangbayan, M.L.A; J.David Hoover.
M.D. Department of Pediatric Surgery, Children's Memorial Hospital,
Chicago, Illinois
The safety and efficacy of laparoscopic splenectomy for pediatric
patients with hematological diseases is being established. We support
this and in addition demonstrate the low use of narcotic analgesics,
which leads to a short length of stay.
We retrospectively reviewed 53 consecutive laparoscopic splenectomies
from 8/96 to 6/00. All splenectomies were performed using a 4 port
lateral technique (n=48) or 6 ports when combined with cholecystectomy
(n=5). The abdominal wall was injected with 0.25% bupivicaine (1cc/kg)
with epinepherine prior to port placement. Post operative pain control
consisted of IV narcotics combined with NSAIDS or acetaminophen with
codiene. Resolution of ileus was required for discharge.
Splenectomies were performed for hereditary spherocytosis (n=2
1), ITP(n=14), thalassemia(n13) and sickle cell disease (n=5). Patient
age ranged from 16 months to 19.4 years (mean9.2 years). Fifteen (28%)
patients required no postoperative IV narcotics, and overall MSO4
use in the remaining 38 patients was 0.12 mg/kg. Forty eight patients
were discharged directly from the 23-hour outpatient stay unit, 3
required a 2 day stay, and 2 required a 3 day stay. There were no
postoperative complications. Only one patient required open conversion
and blood transfusion.
Laparoscopic splenectomy is safe and effective in pediatric patients
with hematologic disease. Low IV narcotic requirements contribute
to resolution of ileus and a short lenght of stay.
s23. LAPAROSCOPIC SPLENECTOMY: GET A GRIP !!
Joy L. Graf, M.D. Marc A. Levitt M.D., Philip L. Glick, M.D. Michael
G. Caty, M.D., Department of Pediatric Surgical Services, Children's
Hospital of Buffalo, State University of New York at Buffalo, Buffalo,
New York, U.S.A.
Laparoscopic splenectomy is often performed with the patient in
the right lateral position. This allows gravity to "retract"
other viscera away from the spleen and allows the surgeon visualization
of the splenic hilum and attachments. Disadvantages of this position
include difficulty in performing an urgent laparotomy or additional
procedures (such as laparoscopic cholecystectomy), and it is also
difficult to manipulate the spleen if the splenic attachments have
been divided, making visualization of the hilar vessels difficult.
To gain the advantage of a prone position and improve visualization
of the hilar vessels, we employed a prototype splenic grasping device.
30 patients who underwent laparoscopic splenectomy were evaluated,
concentrating on the benefit of the Peri-grasp(TM). The instrument
is placed around the spleen after division of the short gastric vessels
and affords the surgeon excellent splenic manipulation.
We used the perigrasp (TM) in 30 laparoscopic splenectomies. 12
patients required additional procedures (laparoscopic cholecystectomy(11),
resection of a gastric duplication(1)). The Peri-grasp(TM) facilitated
ligation of the splenic vessels and made the supine position easier.
One patient required conversion to open splenectomy.
Using a prototype splenic grasper, we believe enhances intra-operative
visualization, splenic mobilization, and optimizes patient positioning.
s24. PEDIATRIC LAPAROSCOPIC SPLENECTOMIE: THE
ANTERIOR APPROCH.
P de LAGAUSIE *(MD), A BONNARD*(MD), P RORLICH **(MD), M BENKERROU***(MD),
N LONG ****(MD), Y AIGRAIN *(MD). Department of pediatric surgery*,
hématology**, sickle cell desease***, anesthésiology****
- Hôpital Robert Debré. 48 Bld Serurier.,PARIS XIX.France
Introduction : we describe an anterior approach of splenectomy
with elective vessels endo ligature in a patient in decubitus position.
Patient and methods : Between January 1996 and may 2000, 35 children
underwent laparoscopic splenectomy; We use anterior pedicle approach
and elective vessel endo-ligature in order to prevent any exogenous
material persistence.
Results : Eight of them also had a concomitant cholecystectomy.
Their age ranged between 1 and 14 years (mean 7 years). 14 childrens
had hereditary spherocytosis, 9 were affected by sickle cell disease,
3 had an idiopathic thrombocytopenia purpura, 2 had beta-thalassemia
and 7 another hemolytic disease. One patient was converted. Mean operative
time was 170 min (range, 115-230 min). Hospital stays ranged from
3 to 15 days (mean : 6). Five patients had complications (3 pneumonia
and 2 deep abscess with successful antibiotic treatment). Median follow-up
was 20 months (2 months- 4 years)without problems regarding procedure.
Discussion : With this technique consisting in first elective arterial
and secondary venal ligature, we preserved blood splenic sequestration
and pancreatic tail lesion. The procedure is more safe. For us, regarding
the low complications rate for this type of patients, and the advantages
of a small abdominal trauma in the postoperative period, the laparoscopic
approach for elective splenectomy and eventual cholecystectomy in
hematological disorders has a technique of choice
s.25 LAPAROSCOPIC CHOLECYSTECTOMY IN CHILDREN
SAFELY REDUCES HOSPITAL STAY.
Deli Xu , Chris Kimber and John Hutson, Department of General Surgery,
Melbourne Unversity, Royal Childrens Hospital and Department of Paediatrics
Monash University for the Victorian Paediatric Surgical Service,Australia
Laparoscopic cholecystectomy (LC) in children has gradually gained
widespread acceptance. Minimal outcome data is available in paediatric
endosurgery.Aim To analyse the effect of introducing LC in paediatric
surgical practice.To compare the hospital stay and complication rates
of LC with open cholecystectomy ( OC).To compare the learning curve
effect with published data. Methods. An independent researcher retrospectively
reviewed all cases of cholecystectomy (OC & LC) performed since
the introduction of LC 8 years ago. Institutional setting: two referral
centres for a population of 4.5 million. Variables analysed included
operating time, surgical expertise, contraindications to LC, complications
and hospital stay using Student's T test. Results. Of the 32 OC performed
( 14 with concomitant splenectomy), 7 had significant common duct
stones. Five of the 86 LC had undergone previous upper abdominal surgery.
There were 3 elective conversions in the LC group. Operating time
was similar in both groups (LC = 96.7 min vs. OC = 96.3 min). There
was no significant difference in complications ( LC = 3% vs. OC= 5%).
Hospital stay was reduced by 2.8 days in the LC cases ( LC = 2.0 +-
1.6 vs. OC = 4.8 +- 3.6, p> 0.05). A widespread usage of LC was
noted in recent years. Conclusions. The introduction of LC into general
paediatric surgical practice has been safe and effective. Hospital
stay is reduced without an increase in major complications.
s26. INTERNET INFORMATION ON PEDIATRIC LAPAROSCOPIC
SURGERY: IS IT ACCESSIBLE TO PATIENTS?
Cynthia Corpron, MD, Steve Golladay, MD, Hurley Medical Center,
Flint, Michigan and Mott Children's Hospital, Ann Arbor, Michigan
Introduction: There are no guidelines, rules or governing bodies
controlling content or checking the validity of information on the
Internet. We performed this study to determine if there was accessible
information available on the Internet to help parents make decisions
about laparoscopic surgery for their children.
Methods: We queried six search engines to identify sites about "laparoscopic
appendectomy". We reviewed the first 25 sites for each , for
accessibility, source, and medical information.
Results: We found the number of "hits" ranged from 144
to over 42,355. One hundred and fifty "hits" led to 64 unique
sites. Ten sites were unreachable. Only 33 (52%) had any medical information
at all. Only 9/53 were directed at patients, and only 3 all journal
article abstracts mentioned children.
Conclusion: Many sites were identified when searching the Internet
for information about laparoscopic appendectomy but none presented
information designed to help parents. The web sites directed at medical
professionals tended to emphasize complications which may alter the
parents decision making and require discussion by the surgeon to adequately
allow the parents to make the best decision regarding laparoscopic
surgery. By reviewing and recommending good web sites or creating
new web sites containing useful information we can most effectively
help parents make informed decisions regarding their child's surgical
treatment.
s.27 LEFT RETROPERITONEOSCOPIC ADRENALECTOMY:
ABOUT TWO CASES
Hossein Allal, MD, Jef Valla, MD, Manuel Lopez, MD, Driss Elazouzi,
MD, Dominique Forgues, MD, René Benoît Galifer, MD. Department
of Pediatric Surgery, Lapeyronie Hospital - Montpellier - France
Benign adrenal pathology is rare in children. The authors report
2 cases of retroperitoneoscopic adrenalectomies.
The first case is a 17 months old femal weighing 2300 grams, with
a clinical and biological hypercortisism with a normal gland in ultrasonography.
The diagnosis suspected was an adrenal hyperplasia. The second case
was a 7 years old femal, with hyperaldosteronism and virilism with
a diagnosis of a left 25 mm sized adrenal adenoma in ultrasonography.
In both cases retroperitoneoscopic adrenalectomy was performed in
a right lateral position. We used 4 trocars. The 7 or 10 mm telescope
was introduced by a mini lombotomy under the extremity of the 12th
rib. The reroperitoneal space was created by the telescope and by
insuflating CO2 gas at 8 mmHg. Three others 3 or 5 mm trocars were
introduced: one above iliaca crest, one in the costo-spinal angle,
and one under the 11th rib to push down the kidney.The dissection
goes on behind the kidney toward the adrenal gland on the upper pole.
Adrenalectomy was performed without difficulty and extracted in a
bag from the optic port.
Operative time was respectively 35 mn and 45 mn and postoperative
discharge 2 days.
Left retroperitoneoscopic adrenalectomy is a safe approach for
benign adrenal tumors. The patient have significantly less postoperative
pain and discomfort and shorter hospital stay.
s28. LAPAROSCOPIC RESECTION OF SMALL ADRENAL
NEUROBRASTOMAS
Kazuhiko Yoshida, MD, Yoji Yamazaki, MD, Masashi Kurobe, MD, Masaki
Kanai, MD, Akihiko Hara, MD, Ryoji Mizuno, Department of Surgery,
The Jikei University School of Medicine, Tokyo, JAPAN
Neuroblastomas (NB) identified by mass screening tests or maternal
ultrasound are characterized by benign features. Some NBs, which do
not regress or progress would have malignant features. Recently, laparoscopic
resection has been applied to the treatment of patients with either
right and left small adrenal NB (2cm). The objective is to describe
our operative technique and preliminary results.
Case1: A left adrenal NB that was detected by mass screening did
not reduce in sized during an observation period of 10 months. The
patient was placed in the lateral decubitus position, and four ports
were inserted. With a cranial traction of the pancreatic tail, tumor
was explored and small arteries were dissected. Lasty, left adrenal
vein was divided after clipping. Case2: A right adrenal NB detected
by maternal ultrasound did not reduce in sized during an observation
of 3 months. With four-port and supine approach, tumor was exposed
with a cranial traction of right hepatic lobe. After arteries around
the tumor were dissected, the right central vein was devided from
inferior vena cava.
Small adrenal NBs that do not regress during a certain observation
period are supposed to be potential candidates for laparoscopic surgery.
Laparoscopic resection of small adrenal NB is safe and effective,
resulting in little blood loss, rapid recovery, and a good cosmetic
outcome.
s29. BILATERAL LAPAROSCOPIC ADRENALECTOMY IN
A PATIENT WITH A PRIMARY ADRENAL HYPERPLASIA
María M Bailez; Gastón Elmo;Luciano Korman ; Marcelo
Martinez Ferro and Fermín Prieto, Hospital J.P. Garrahan. BS
AS Argentina
There are a few reports presenting laparoscopic adrenalectomies
in children including a ganglioneuroma, a pheocromocitoma , a virilizing
tumor and small neuroblastomas.
We present a 4 years old male with a primary pigmented nodular adrenocortical
disease (PPNAD) who underwent a bilateral laparoscopic adrenalectomy.He
was admitted for a Cushing syndrome. Magnetic resonance showed enlarged
adrenal glands with central nodularity . Plasma ACTH levels were low
and didn´t respond to an IV inyection of CRH. Cortisol levels
were high and were not suppressed by dexamethasone.
A transperitoneal approach with 5 ports was used. The ultrasonic
dissector was used for all the dissection including adrenals arteries
and veins.. The left gland proved to be more friable and difficult
to locate than the rigth one which was easily circunferentially dissected
with no need of dividing the right triangular ligament . Extraction
of both glands was performed through a 12 mm port . The patient recovered
uneventfully . He has been followed without recurrence of his disease
for 10 months.
PPNAD is a rare cause of Cushing syndrome in infants , children
and young adults. The adrenal glands range from small to slightly
enlarged and contain multiple nodules from microscopic up to 6mm in
diameter. Its treatment is bilateral adrenalectomy These 2 facts (
small glands and bilateral resection) suggest that laparoscopy is
the approach of choice
s30. CHALLENGES OF LAPAROSCOPIC RESECTION OF
ABDOMINAL NEUROBLASTOMA WITH LYMPHADENECTOMY
Tadashi Iwanaka, M.D., Mari Arai, M.D., Mitsuhiro Ito, M.D., Hiroshi
Kawashima, M.D., Kimio Matoba, M.D., Satohiko Imaizumi, M.D. Department
of Surgery, Saitama Children's Medical Center, Iwatsuki, Saitama,
Japan
Background: The laparoscopic procedure of total resection of abdominal
neuroblastoma combined with lymphadenectomy has not been reviewed
in English literature. The aim of this study is to evaluate the significance
and accuracy of laparoscopic resection of abdominal neuroblastoma.
Methods and Procedures: Since July 1997, 5 patients with abdominal
neuroblastoma underwent laparoscopic resection combined with lymphadenectomy
or lymph nodes sampling. After 3 or 4 ports were inserted, a 5-mm
harmonic scalpel and electrocautery were used to dissect the retroperitoneum,
mobilize the colon, and approach the neuroblastoma. Large blood vessels,
such as inferior vena cava and renal vessels, were mobilized by blunt
dissection. Neuroblastoma was removed in an endoscopic bag through
a 12-mm umbilical port. Additional lymphadenectomy or lymph nodes
sampling, especially for paraaortic and pararenal lymph nodes swelling,
was performed simultaneously. The length of operation, intraoperative
blood loss, resectability and complications in 5 cases were retrospectively
reviewed and evaluated.
Results: Four cases were accomplished laparoscopically, but one
case was converted to open procedure due to poor visualization around
large vessels. Mean length of operation time and intraoperative blood
loss were 135 minutes and 52 ml, respectively.
Conclusions: Good visualization of primary tumor and large vessels
is the most important factor for successful completion of this procedure
laparoscopically.
s31. THE VALUE OF ENDOSCOPY IN THE MANAGEMENT
OF PAEDIATRIC TUMOURS
Gordon MacKinlay, MD, Fraser Munro, MD, Hamish Wallace*, MD, Departments
of Paediatric Surgery and Oncology*, The Royal Hospital for Sick Children,
Edinburgh, Scotland.
Objective: To evaluate our experience in the management of tumours
in children. In most paediatric tumours these days, radical primary
surgery with removal of massive tumours is no longer appropriate.
Increasingly pre-operative chemotherapy has been shown to be beneficial
in reducing the size of tumours, eradicating microscopic and macroscopic
secondary deposits and facilitating subsequent surgical resection.
Methods: Selective trucut biopsies under laparoscopic or thoracoscopic
guidance were taken as part of the diagnostic evaluation of 20 patients.
Larger biopsies were taken with biopsy forceps, endoloops or staplers.
Tumours are evaluated endoscopically and may also be removed Iaparoscopically
(such as ovarian (2) and adrenal (1) tumours).
Results: Laparoscopic biopsy of tumours has ensured adequate and
diagnostic tumour biopsies in 100% of cases whereas blind percutaneous
biopsies and radiologically guided biopsies may not be diagnostic
in up to 10% of cases. Laparoscopic assessment of patients with abdominal
pain (2 cases) can exclude appendicitis and avoid open surgery. Lung
metastases have been biopsied (4) and completely resected in 3 cases.
Conclusions: Minimally invasive techniques are a valuable adjunct
in the management of children with abdominal and thoracic tumours,
primary and secondary. Small tumours may safely be resected endoscopically
and minimise discomfort and scarring as well as allowing early introduction
of chemotherapy where appropriate.
s32.THE USE OF THORACOSCOPY IN THE EVALUATION
AND TREATMENT OF PEDIATRIC ONCOLOGY PATIENTS
Steven Rothenberg M.D., Melissa Brooks, Tom Smith M.D., The Hospital
For Infants and Children At Presbyterian /St Lukes
The application of thoracoscopy in the evaluation and treatment
of pediatric patients with malignant disease remains controversial
but there is little hard data. This paper describes our experience
over a seven year period.
From June 1993 to July 2000, 47 patients underwent 58 thoracoscopic
procedures for diagnosis and treatment.
Ages ranged from 2 months to 21 years (mean 12.2) and weight from
4.2 to 100 Kg (mean 48.7).There were 31 males and 16 females. Procedures
included 40 lung wedge resections, 10 biopsy or resections of mediastinal
masses, One left lower lobectomy, and 7 diagnostic procedures converted
to open thoracotomy.
The average operative time was 48 min. for lung biopsy and 90 min
for mediastinal masses.The average chest tube duration was 0.3 and
0.8 days respectively. Average hospital stay was 1 and 1.5 days. Diagnosis
was obtained in all but one case (98.37%). There were no operative
complications.
Only 2 patients, both with osteogenic sarcoma had recurrence of
their disease and this was at different sites.
This experience shows thoracoscopy to be a safe and valuable tool
in the evaluation and treatment of pediatric oncology patients.
s33. THORACOSCOPIC THYMECTOMY( TT) SAFELY REDUCES
HOSPITAL STAY.
Chris Kimber, Alex Auldist, Y Liam and Peter Borzi Royal Children's
Hospital Melbourne, National Institute Paediatrics Hanoi Vietnam and
Royal Children's Hospital Brisbane.
Thymectomy is rarely required for severe myasthenia gravis. Standard
sternotomy has significant long-term morbidity.
Aim . To compare the hospital stay and complication rates of TT
with standard sternotomy.
Methods. Three children aged 8-13 underwent Left axillary thoracoscopic
thymectomy. Variables analysed included operating time, complications
and hospital stay.
Results Hospital stay was less than 48 hours in all 3 cases. Operating
time was less than 120 min. There were no complications. Standard
sternotomy has a median hospital stay of 4 days in our institute.
There has been no evidence of thymic recurrence.
Conclusion: The introduction of TT into general paediatric surgical
practice has been safe and effective. Hospital stay is reduced without
an increase in major complications. No major adverse event occurred
during this learning curve.
s34. MANAGEMENT OF HEPATIC ABSCESS IN CHRONIC
GRANULOMATOUS DISEASE BY LAPAROSCOPIC DEBRIDEMENT AND OMENTOPLASTY
Hirotoshi Yamamoto, MD., PhD., Mitsuhiro Yoshida, MD., Kwan-John
Lee, MD., Yukihiro Inomata, MD., PhD., Department of Pediatric Surgery,
Kumamoto University School of Medicine, Kumamoto, Japan
An 8-year-old boy with chronic granulomatous disease (CGD) was admitted
to our hospital due to a hepatic abscess. Ultrasound (US) showed an
abscess 2.5-cm diameter in the left lobe of the liver. Despite treatment
with antibiotics and gamma interferon for three months, the abscess
increased in size. Percutaneous drainage of the hepatic abscess was
not technically feasible because US revealed mixed cystic and solid
areas in the cavity. Surgical debridement and omentoplasty was performed
laparoscopically.
A10-mm trocar was inserted through an umbilical incision and CO2
insufflation was begun. A10-mm laproscope was placed through an umbilical
port. Three 10-mm trocars were placed in the abdomen for use as working
ports. The pneumoperitoneum was decompressed after abdominal wall
traction with a curved Kirschner wire. Overlying liver tissue was
unroofed with an electorocautery and an ultrasonic coagulation cutting
device, and the cavity was debrided under laparoscopy in combination
with color-flow Doppler imaging. After surgical debridement, the cavity
was filled with a greater omentum flap. The patient was treated with
antibiotics and gamma interferon postoperatively. A repeat US examination
of the liver13 months after surgery showed that the hepatic mass had
disappeared.
Laparoscopic debridement in combination with an omental flap seems
to be an effective therapy for hepatic abscess in CGD.
s35. APPLICATION OF SINGLE PUNCTURE METHOD TO
LAPAROSCOPIC SURGERIES
Akio Kubota, M.D., Hiroomi Okuyama, M.D., Takaharu Oue, M.D., Ryoichi
Ikegami, M.D., Masashi Kamiyama, M.D., *Takuya Kosumi, M.D., Katsuji
Yamauchi, M.D., Takashi Nogami, M.D., Noriaki Usui, M.D., Makoto Yagi,
M.D., Department of Pediatric Surgery, Osaka Medical Center for Maternal
and Child Health. *Department of Surgery II, Kinki University School
of Medicne, Osaka, Japan
PURPOSE: In order to establish minimally invasive and cosmetic technique
to perform laparoscopic surgeries, we applied a single puncture method
to pediatric cases.
MATERIALS AND METHODS: A two-month-old girl with ovarian cyst, a
five-month-old boy with omphalomesenteric duct remnant (ODR) and 21
cases with cerebral palsy (CP) with or without gastroesophageal reflux
(GER) were included in the study. In the first case, through an umbilical
semicircular incision, laparoscopy and ovarian cystectomy were performed.
The second case presented ascites discharge from the herniated umbilicus.
A laparoscope was inserted through an umbilical arcuate incision to
make a definitive diagnosis, and the entire ODR was resected. In cases
of CP, simple gastrostomy was made in four and gastrostomy concomitant
with laparoscopic fundoplication was made in 17 with GER. At the site
for gastrostomy a laparoscope was inserted and gastrostomy was made
at the site.
RESULTS: In all the cases, through a single incision, laparoscopic
examination and radical operations could be performed safely. The
results were cosmetically excellent. No complication, except minor
infections in two cases, was encountered.
CONCLUSION: The single puncture methods demonstrated the feasibility
of minimally invasive and cosmetically excellent techniques for laparoscopic
surgery.
s36. EARLY EXPERIENCE WITH PORCINE HEPATICOJEJUNOSTOMY
USING ZEUS ROBOTIC TECHNOLOGY
Celeste Hollands, MD, Laramie Dixey, RN, Louisiana State University
Health Sciences Center-Shreveport, Shreveport, Louisiana
Introduction: This study examines the technical feasibility
of performing robotic-assisted hepaticojejunostomy using ZEUS technology.
Minimally invasive pediatric surgery is often limited by a small workspace
as well as the inability to perform microsurgical anastomoses. ZEUS
robotic technology facilitates the safe performance of precise anastomoses
of 2-15mm in diameter thus potentially allowing this traditionally
open operation to be performed entirely in a laparoendoscopic environment.
Methods: 10 piglets (5.0-7.5 kilograms) were divided into 2 groups:
a control group (n=5, standard laparoscopic hepaticojejunostomy) and
an experimental group (n=5, ZEUS assisted hepaticojejunostomy). Anesthesia,
surgery, anastomosis, and robotic set-up times and complications were
recorded. This was a non-survivor protocol approved by the Animal
Resource Committee. Statistical analysis was performed using the two-tailed
student's t-test.
Results: C=control, Z=experimental. Anesthesia time (C:120+-9;Z:147+-25,p=0.12);
Surgery time (C:95+-7;Z:134+-26,p=0.05); Anastomosis time (C:66+-4;Z:93+-21,p=0.08);
AESOP set-up (C:1+-1;Z:3+-4,p=0.32); ZEUS set-up (C:n/a;Z:10+-8,p=n/a)
Times in minutes. Complications (C:7-3 leaks, 3 tears, 1 conversion;Z:1-1
conversion).
Conclusions: The data supports the hypothesis that robotic-assisted
hepaticojejunostomy is technically feasible and may be preferable
to standard laparoscopic techniques.
s37. PREEMPTIVE ANALGESIA FOR PEDIATRIC PERITONEOSCOPY,
COMPARING CAUDAL AND ACETAMINOPHEN
Steve Golladay, MD, Sue Hutter, CRNA, Eric Koehn, RNA, Thurman
Hunt, MD, Rao Gutta, MD, Francis Gerbasi, PhD, Cynthia Corpron, MD,
Agnes Hagan, CRNA, Thomas Dell, CRNA, Karen Selley, CRNA Huriey Medical
Center, Flint, Michigan and Mott Children's Hospital, Ann Arbor, Michigan
Although caudal block and acetaminophen have shown efficacy in postoperative
pediatric pain management, they have not been compared in efficacy
following peritoneoscopy. The study population were ASA I or II children
from 55 weeks postconceptual age to 10 years of age having peritoneoscopy.
Random assignment to preoperative caudal using 0.6 ml/kg bupivacaine
or preoperative rectal acetaminopen 30 mg/kg with each group receiving
acetaminophen 2Omg/kg/6h x 4 doses. A blinded observer using the Objective
Pain Scale assessed upon awakening, in PACU, and at discharge. A phone
survey of satisfaction occurred at one day.
Acetaminophen was used in 18 patients and 14 had a caudal. The initial
PACU score was 4.1±3.1 for acetaminophen and 2.3±3.0 (p+0.03).
Fifty six percent of the acetaminophen group needed added narcotic
whereas only 22% of those with caudal did (p=0.02). Forty three percent
of the acetaminophen group had nausea compared to 11 % of the caudal
group (p=0.023). There was no difference in satisfaction. The results
support the use of caudal as preemptive analgesia for peritoneoscopy
in children.
s38. LAPAROSCOPIC RESECTION OF AN HEPATIC FOCAL
LESION
Christine GRAPIN, M.D1, Fawaz FAYAD, M.D1, Gérard CHAMPAULT
M.D2, Bruno POULET, M.D3, Catherine GUETTIER,M.D.3
Department of Pediatric Surgery1, Department of General Surgery2,
Department of Anatomopathology3
Hôpital Jean Verdier - Bondy - Paris - France
PURPOSE: The authors describe a laparoscopic approach of a benign
hepatic lesion (focal nodular hyperplasia).
MATERIAL AND METHOD: A 3 years old boy, presents a focal nodular
hyperplasia of the right liver. Resection was performed laparoscopically
using ultrasonic dissection by <<Ultrascissor>> device.
The patient was discharged at the 4th day without any complaints.
CONCLUSION: The laparoscopic approach of the hepatic benign lesion
in children is a feasible and satisfactory technique. The use of ultrasonic
dissection is very helpful to decrease bleedings.
s39. THE FORGOTTEN MECKEL'S DIVERTICULUM: ROLE
OF LAPAROSCOPY
Amulya Saxena, MD, Günter Willital, MD, Pediatric Surgical
University Clinic, Munster, Germany
Meckel's diverticulum has an incidence of approximately 2 percent
in the population and may be present at any age. Due to the presence
of hetroptrophic tissue in the diverticulum and its varied clinical
presentation that could manifest as right lower abdominal pain, this
tissue should be identified during appendectomy.
From June 1994 to June 2000 identification of Meckel's diverticulum
was performed on all children (5 to 14 years age) undergoing laparoscopic
appendectomy using 5mm Duffner instruments. Retrograde examination
of the ileum in 124 children identified this tissue positively in
3 cases at distances of approximately 20- 30 cms.
In these cases the paraumbilical trocar placement incision was slightly
enlarged and the diverticulum was brought outside the abdominal cavity
where a resection was performed followed by a ileo-ileal anastomosis
after which the bowel was returned to the abdominal cavity. The diagnosis
was missed in one child who later presented clinical symptoms.
Identification of the Meckel's diverticulum must be compulsory in
all children undergoing laparoscopic appendectomy. Retrograde examination
of the ileum laparoscopically is easy and can be performed within
a matter of 2-5 minutes. Diverticulum resection does not require any
additional incision. Since the risk of developing symptomatic problems
decrease with age, it is appropriate to carry out resection of the
incidentally found diverticulum in young children.
s40. LAPAROSCOPY FOR DIAGNOSIS AND TREATMENT
OF GASTROINTESTINAL BLEEDING IN CHILDREN
Marc A. Levitt M.D., Philip L. Glick, M.D. Michael G. Caty, M.D;
Department of Pediatric Surgical Services, Children's Hospital of
Buffalo, State University of New York at Buffalo, Buffalo, New York,
U.S.A.
The source of gastrointestinal bleeding in children is usually readily
identifiable with a standard evaluation. Rarely, the bleeding is occult
and may arise from sources such as an intestinal duplication, Meckel's
diverticulum, or Henoch-Schonlein purpura. Laparoscopy is an ideal
modality to investigate such occult bleeding and also allows for definitive
therapy at the time of evaluation.
In a one year period 64 patients were evaluated for gastrointestinal
bleeding. In four patients, the source of bleeding could not be ascertained
by upper or lower endoscopy.
Laparoscopy was utilized both for diagnosis and treatment for four
patients with occult gastrointestinal bleeding. In three patients,
the source was a bleeding Meckel's diverticulum, two of these were
identified preoperatively with Meckel's scan. Of the four, one patient
had Henoch-Schonlein purpura as the cause. A single trocar technique
was utilized in one case. Laparoscopic assisted small bowel resection
was performed in three patients.
Laparoscopy is a valuable tool in both diagnosis and treatment
of occult gastrointestinal bleeding in children.
s41. PERCUTANEOUS ENDOSCOPIC COLOSTOMY: A NEW
TECHNIQUE
MUNTHER HADDAD, M.D.,SIMON CLARKE , M.D., JOHN FELL, MD, NIMAH
GEOGHEGAN R.N., NICK MADDEN, M.D. , CHELSEA & WESTMINSTER HOSPITAL,LONDON
,UK
AIM: To describe the preliminary findings of a new technique in
five patients with intractable constipation and soiling with distal
slow colonic transit.
METHODS:
(i) Various criteria were used to select, including high motivation
levels of family,preoperative transit studies demonstrating very delayed
slow colonic transit.
(ii) Technique: Limited colonoscopy,percutaneos approach of inserting;under
directvision;a corflo type gastrostomy tube into the distal part of
the descending colon.
RESULTS: All patients reported an improvement in quality of life
and all were attending school more frequently. Analysed in a clinical
setting with a clean score. 0= soiling; +1= less soiling but still
dirty ;2 patients ; +2= mostly clean with occasional accidents; +3=
clean in between enemas with no soiling 3 patients.
Follow up ( 3 months-21 months ) mean=14 All had minor complications
including granuloma,leakage,infectionand abdominal pain with enemas.
CONCLUSION: We have demonstrated a simpler method of creating access
to the distal colon without the need for open surgery. Careful patient
selection as well as intensive pre and post operative work up at home
using a specialised nursing input plays a large part in its success.
s42. LAPAROSCOPIC ENDORECTAL PULL
THROUGH FOR CHRONIC CONSTIPATION
Ashley H. Vernon. MD, Timothy D. Kane, MD, Keith E. Georgeson,
MD, Division of Pediatric Surgery, University of Alabama, Birmingham,
Alabama
INTRODUCTION: Chronic constipation is common in the pediatric population.
There is a subgroup of patients refractory to aggressive medical management
who are candidates for surgery. Procedures utilized for the most severely
compromised patients range from limited resections to total colectomy
& ileorectostomy. We present five patients with intractable symptoms
who underwent laparoscopic partial colectomy and endorectal pull through
for the treatment of chronic constipation.
METHODS: Retrospective chart review, clinical follow up and patient
survey were undertaken for this study.
RESULTS: Five patients underwent laparoscopic pull through for
chronic constipation at the Children's Hospital of Alabama since 3/25/97.
Preoperatively, all five patients had symptoms present for more than
three years and had bowel movements less than one per month with maximal
medical therapy. Operative time for pull through averaged 3h30min
(range 3:01-4:19); blood loss was minimal. Average length of stay
was 4.4 days. All patients were continent & had regular BMs at
discharge. Follow up, reveals an average of 3 BMs per day without
medication and no complications. All patients were satisfied.
CONCLUSIONS: It is concluded that laparoscopic endorectal pull through
constitutes a safe and effective treatment for chronic constipation
and should be considered in a small number of patients with symptoms
that are refractory to all usual medical treatment.
s43. LAPAROSCOPIC ASSISTED COLON RESECTION FOR
SEVERE IDIOPATHIC CONSTIPATION WITH
MEGARECTOSIGMOID
Marc A. Levitt M.D., Philip L. Glick, M.D. Michael G. Caty, M.D.
Department of Pediatric Surgical Services, Children's Hospital of
Buffalo, State University of New York at Buffalo, Buffalo, New York,
U.S.A.
A subset of patients with severe constipation require massive amounts
of laxatives and/or may develop overflow pseudoincontinence. Some
of these patients develop a megarectosigmoid with normal caliber of
the remaining bowel, and may benefit from resection of the dilated
colonic segment.
In a 5 year period, 164 patients were referred for evaluation of
severe constipation. 93 patients had idiopathic constipation, 41 had
Hirschsprung's disease, and 30 had previous anorectal malformation
repair. Of those with idiopathic constipation, 5 required massive
amounts of laxatives for bowel management, and also had megarectosigmoids.
All patients were first managed with a strict bowel management regimen.
A laparoscopic sigmoid resection was offered to these 5 patients with
the goal to reduce their laxative requirements.
All 5 patients presented with incontinence and required fecal disimpaction.
With an aggressive bowel management regimen, all were found to in
fact have overflow pseudoincontinence, and with high doses of laxatives
were able to have daily bowel movements. All 5 patients had a dilated
megarectosigmoid with normal caliber remaining colon, and underwent
laparoscopic assisted rectosigmoid resection. Postoperatively all
5 have significantly reduced their laxative requirements, all are
continent and have daily bowel movements.
Laparoscopic assisted rectosigmoid resection is an ideal approach
for a select group of patients with intractable idiopathic constipation.
s44. COLONOSCOPY ASSISTED LAPAROSCOPIC REPAIR
OF AN IATROGENIC NEORECTAL PERFORATION IN A CHILD WITH ULCEROUS COLITIS.
Klaus Schaarschmidt, MD, Andreas Kolberg-Schwerdt, MD, Michael
Lempe MD, Centre of Pediatric Surgery Berlin-Buch, Germany
Objective: We report a 12 -year-old boy, sustaining a dorsal neorectal
perforation on neorectoscopy in a height of 15 cm but still below
the peritoneal reflection. 2 months before, the boy had had laparoscopic
colectomy and proctomucosectomy, ileoanal anastomosis and laparoscopic
ileostomy
Methods and Procedures: The injury was noticed immediately, a neocolonoscopy
was performed and a foley catheter could be placed under colonoscopic
sight through the neorectal wall defect. The balloon of the catheter
was inflated and the abdomen prepared. From one 10mm umbilical and
three 5mm mid and lower abdominal accesses the rectal wall defect,
marked by the foley ballon was easily retrieved on laparoscopic mobilisation
of the rectum. The bladder was hitched to the anterior abdominal wall.
The edges of the bowel injury were trimmed by scissors to obtain bleeding
and closed by a double row of transverse inverting non absorbable
sutures. The repair was tested by colonoscopic air inflation under
water. The abdomen was irrigated liberally and the rectum was drained
by retrorectal drainage.
Results: The postoperative course was uneventful, colonoscopic control
showed no stenosis and the ileostomy could be closed 3 weeks later.
Conclusion: Laparoscopic repair of rectal perforation is effective,
our technique of colonoscopic foley catheter placement helps considerably
in the localisation of the injury particularly in a previously operated
area.
s45. LAPAROSCOPIC INTRACORPORAL SUTURELESS COMPRESSION
ANASTOMOSIS A NEW METHOD OF BOWEL RESECTION IN INFLAMMATORY BOWEL
DISEASE OF CHILDHOOD.
Klaus Schaarschmidt MD, Andreas Kolberg-Schwerdt MD, Michael Lempe
MD, Frank schlesinger MD, Centre of Pediatric Surgery, Berlin-Buch
Objective: Entirely laparoscopic small and large bowel resection
is an advanced procedure in children. Stapler techniques produce a
side to side anastomosis, which is inferior to end to end anastomoses.
In Crohns disease, reaction to foreign bodies like staples or suture
material may lead to fistula formation. Therefore we evaluated laparoscopic
sutureless compression anastomosis using a Valtrac ring.
Methods and Procedures: From one 10 mm umbilical and three 5mm abdominal
accesses, the resection of the diseased bowel segment was completed.
The specimen was removed and the Valtrac ring introduced via the umbilical
access. Two intracorporal purse string sutures were placed laparoscopically
in 2/0 monofilament suture over the halves of the Valtrac ring, and
the anastomosis was closed by compression of the ring by two bowel
clamps. In the first child a laparoscopy assited technique was used
for a sigmoid resection, in the second the Ileocecal resection was
performed by entirely intracorporeal technique.
Results: Both postoperative courses were uneventful, the fragments
of the bioabsorbable Valtrac ring were passed anally after 2 and three
weeks. By colonoscopy sutureless compression anastomosis is virtually
invisible after 3-4 weeks.
Conclusion: From this preliminary experience an entirely intracorporeal
laparoscopic sutureless compression anastomosis with laparoscopicallly
hand sewn purse string sutures yields excellent results in inflammatory
bowel disease of childhood.
s46. LAPAROSCOPIC ABDOMINAL APPROACH FOR THE
TREATMENT OF CLOACAS AND A RECTO-VESICAL FISTULA
María M. Bailez ; Victor Dibenedetto and Marcelo Martinez
Ferro Hospital J. P. Garrahan . Bs As Argentina
We present 3 patients with high anorrectal anomalies treated with
a combined laparoscopic and posterior sagital approach.
Case 1 : A 6 months old boy with a grade IV left vesicoureteral
reflux , normal sacrum and a sigmoid loop colostomy. Distal cologram
showed a very high rectum ending in the bladder neck. A combined restricted
sagital approach followed by a laparoscopic treatment of the fistula
were done. The rectum was descended under laparoscopic vission.
Case 2 and 3: A 10 m. and a 4 y. old females were admitted for cloacal
reconstruction . Rectum was high , ending between 2 dilated vaginas
Both had a transverse diverted colostomy and had been managed with
irrigation of the distal loop and intermitent catheterization of the
vaginas through the cloacal channell.
After a total urogenital sinus mobilization ( 4 and 9 cm long) through
the posterior sagital approach , the rectum was still high and its
mobilization uncomfortable . Laparoscopy showed a dilated rectum ending
high between 2 vaginas , next to uterine cervix junctions in both
. It was easily dissected and the fistula transected between endosutures
. Tailoring of the rectum and anorrectoplasty were completed through
the posterior sagital approach.Dissection of urethrovaginal septum
was needed in case 3.
About 10 % of ARM require an abdominal approach. Laparoscopy gives
an optimal view of the pelvis and helps to achieve a very low dissection
of the fistula with minimal trauma.
s47. LAPAROSCOPIC ASSISTED ABDOMINOPERINEAL PULLTHROUGH
FOR ANORECTAL AGENESIS (LAPP) -EARLY EXPERIENCES
P A Borzi, A J Mackay, M M Lander and R M Walker; Mater and Royal
Childrens' Hospitals; Brisbane Australia
We present our short experience with the techique of laparoscopic
rectal mobilisation, division of fistula and positioning of the neoanus
by simultaneous perineal muscle stimulation and visualization of the
pelvic floor. A Step port (Innerdyne) was used to achieve the pullthrough.
Over an 18-month period 11 children have been selected for a LAPP
procedure. During this time excluded cases included presence of a
perineal fistula, low vaginal fistula and suspicion of a low anomaly
without fistula. There were 3 females and 8 males. The anatomical
anomalies included high confluence cloaca(1), anorectal agenesis with
high rectovaginal fistula(2), rectovesical fistula(1), rectoprostatic
fistula(3), rectomembraneous fistula(1), rectobulbar fistula(2) and
imperforate anal membrane(1). The age range was 5 weeks to 6 months
(av 7 weeks) with preoperative weights of 4.6 to 7.9 kg. One child
had a primary neonatal LAPP and the rest had an initial colostomy
with delayed LAPP
Discharge was achieved within 48 hrs postoperatively in all except
one child. Regular anal dilatations started at between 7 to 10 days.
This one delayed discharge arose as intraoperative faecal spill ultimately
necessitating laparotomy for peritoneal lavage. Despite this the LAPP
was completed initially. Difficulty arose with distal fistula mobilization
as it turned "around the corner" in the presence of a large
faecoloma
Early followup is encouraging. CT/MRI of the pelvic floor in 6
children is to be presented
We recommend from our preliminary experience that careful preoperative
studies to level the fistula is essential. Adequate preoperative evacuation
of the bowel distal to the stoma is to be mandatory for pelvic dissection.
If the fistula is distal to the membraneous urethra, we would consider
temporarily leaving the laparoscopic component, with completion as
a "limited PSARP" after localization of the muscle cuff
by nerve stimulator and insertion of the initial veres needle and
expandable cuff
s48. COLON ENDOSURGERY IN CHILDHOOD: PERSONAL
EXPERIENCE
Francisco J. Berchi M.D., I.Cano M.D.,M.I.Benavent M.D., E. Portela
M.D., A.Garcia M.D., Pediatric Surgery Department, HUMI, Hospital
12 de Octubre, University Complutense, Madrid/Spain
Introduction:Laparoscopic colectomy(subtotal or total) is an advanced
celioscopic procedure,which can be employed in colonstenose,after
an inflammatory disease.
Methods and Procedures:The surgeon´s preferred technique for
open operation should be utilized laparoscopically Colonic dissection
in each case. Variety of methods can be employed to provide anastomosis.
Stapled anastomosis can be performed in the usual manner for open
surgery.Laparoscopic approach for colectomy adds the potential for
degreased postoperative stress and pain,more rapid return of bowel
function and better cosmetic appearance.We present our experience
from 10 colon resections.The surgical procedure took 2-8 h to perform.
Results: Bowel obstruction ocurred in 2 patients.1 Child needed
re-operation with new anastomosis and another patient often dilation
without operation.Laparoscopic total colectomy require an advanced
level of endoscopic surgical skill.We moster our technique and postoperative
results.
Conclusions:In pediatric centers with laparoscopic surgical expertise
the procedure in subtotal or total colectomy can be safety introduced
for the management of colon-stenose.
s49. LAPAROSCOPIC SURGERY FOR CONGENITAL COLO-RECTAL
DISEASE IN CHILDREN
Takehara H., Tashiro S., Ishibashi H. & Yawada Y., Department
of Surgery, University of Tokushima, School of Medicine
Between June 1996 and September 2000, laparoscopic colorectal surgery
were performed in 14 children (11 boys and 3 girls). They consisted
of 11 with HirschsprungÕs disease, two with con-genital segmental
dilation of the rectum and one with anal atresia with recto-vesical
fistula. Their ages ranged from 16 days to 10 years (4 neonates, 5
infants, 2 toddlers and 3 school children) with weighing from 3.4
kg to 29 kg. Eleven patients with Hirsch-sprungÕs disease underwent
laparoscopically endorectal pull-through with colon inverting method
using a venous stripper. Two with congenital segmental dilation of
the rectum were also treated with laparoscopic low anterior resection
using EEA instrument transanally. One with anal atresia was treated
with laparoscopic dissection for recto-vesical fistula and neoanus
was constructed by PenaÕs procedure (posterior sagittal anorectoplasty)
No laparoscopic procedure required conversion to open lapa-rotomy.
There were no other major intraoperative or early post-operative complications.
Oral feeding was resumed 3 to 4 days after surgery. No patients have
developed enterocolitis or anal stricture.
We conclude that the laparoscopic surgery in children with congenital
colo-rectal disease can be carried out more safely and no more time
than similar open procedures even in neonate. These benefits include
no need stoma care without anal atresia of high type, shorter operative
time and hospitalization, and fewer complications.
s50. LAPAROSCOPIC THERAPY OF OVARIAN CYSTS IN
CHILDREN
Clark Gorsler M.D., Enrico Danzer, Felix Schier M.D., Department
of Pediatric Surgery, University Medical Center Jena, Germany
Objective: To report the clinical experience with 40 ovarian cysts
treated laparoscopically. Material and Method: 40 girls were treated
for ovarian cysts (age 2 days to 17 years). The diagnosis had been
established prenatally in 7 girls. A window was opened with 2-mm instruments.
When both layers were identified easily, the inner layer was removed.
Results: 27 cyst were on the right, 8 on the left side, 5 girls
had bilateral cysts. The cysts were upon laparoscopy so small that
they were left untouched in two girls. In 9 girls the cysts had ruptured
spontaneously. In 17 girls, a window was created, in 2 the ovary was
removed laparoscopically and in 5 the procedure had to be converted
to an open approach for removal of the ovary.
Conclusion: Laparoscopy is well suited for diagnosis and treatment
of ovarian lesions. Conversions are not infrequent in the removal
on ill-defined tumors.
s51. LAPAROSCOPIC VARICOCELE LIGATION IN CHILDREN
AND ADOLESCENTS
Martin A. Koyle, M.D. and Peter D. Furness III, M.D., The Childrens
Hospital, Department of Pediatric Urology and The University of Colorado
School of Medicine, Denver, Colorado
PURPOSE: To assess laparoscopic high spermatic cord interruption
(PALOMO) in male children and adolescents.
MATERIALS AND METHODS: Between 1994 and 2000, all patients with
surgical indications for varicocelectomy were offered the choices
of annual observation without surgery, radiographic embolization,
standard open correction via suprainguinal, inguinal or subinguinal
access,or laparoscopic venous interruption (LVE). 38 of 42 patients
requested LVE and are the subject of analysis.
RESULTS: Patient ages ranged from 10-18 (mean-14.6). Operating time
as18-52 minutes. In 3 patients adhesions were lysed laparoscopically
but otherwise no ancillary procedures were paerformed. No intraoperative/early
postoperative complications were identified. All patients were back
to full activity and off narcotics within 48 hours of surgery. There
were no recurrent varicoceles at a minimum 6 months postoperatively.
No testes were lost but 2 patients did develop ipsilateral hydroceles.
CONCLUSIONS: LVE is a rapid, effective method to treat varicoceles
in young males. Given all therapeutic options, it appears that when
given informed consent, LVE is preferable to most males in adolescent
and prepubertal age groups. As with the open Palomo technique, hydrocele
formation may occur in 5-10% of patients postoperatively
s52. ENDOSCOPIC SUBURETERIC INJECTION OF COLLAGEN
-- EARLY EXPERIENCE AT THE ROYAL HOSPITAL FOR SICK CHILDREN, EDINBURGH
Gordon MacKinlav, M.D., Dale Loh, M.D. and Phillip Hammond, M.D.,
Department of Paediatric Surgery, Royal Hospital for Sick Children,
Edinburgh, Scotland
Objective: To ascertain the efficacy of collagen in
controlling vesicoureteric reflux and to determine if there were any
complications or recurrences.
Methods and Procedures: Retrospective case-note review of patients
treated from February 1998 till March 2000. A total of 61 patients
(46 girls and 15 boys) were identified with 92 refluxing units. Pre-operatively,
all underwent an intradermal collagen skin test. At cystoscopy, approximately
0.5ml. -- 1ml. of glutaraldehyde cross-linked bovine dermal collagen
was injected into a sub-ureteric position. Post-operatively, all underwent
a renal ultrasound at one month and a MCUG/Mag-3 renogram or a direct
puncture cystogram at 3 months. A comparison with our previous experience
with Macroplastique was made.
Results: Vesico-ureteric reflux was abolished in 72 (79%) of the
92 ureteral units after one injection. In another 13 (14%) ureteral
units, reflux was controlled after 2 injections. No post-operative
complications, like obstruction were noted. One recurrence bilaterally
was noted a year after bilateral STING's were carried out.
Conclusion: Our early results are comparable to other published
series. Collagen seems to be just as effective as PTFE and more effective
than Macroplastique in our unit in the early control of VUR.
s53. ONE-STAGE LAPAROSCOPIC HEMI-NEPHROURETERECTOMY
WITH EXCISION OF URETEROCELE AND URETERIC REIMPLANTATION IN THE TREATMENT
OF DUPLEX KIDNEYS WITH NON-FUNCTIONONG MOIETIES AND COMPLICATING URETEROCELES
CK Yeung, MD, YH Tam, WG Manson, KH Lee, Division of Paediatric
Surgery, Department of Surgery, Chinese University of Hong Kong, Prince
of Wales Hospital, Hong Kong, China
Objective: Over the past two decades, a staged approach with the
combined use of endoscopic incision of ureterocele and partial nephrectomy
has been adopted by most for the management of duplex kidneys with
non-functioning moieties associated with complicating ectopic ureteroceles.
However, the unsatisfactory long-term results of endoscopic incision
alone for ectopic ureteroceles has swung the management trend back
towards the more traditional total radical surgical reconstruction.
We herein report our initial experience of one-stage laparoscopic
hemi-nephroureterectomy with simultaneous excision of ureterocele,
repair of bladder neck and reimplantation of the normal moiety ureter
in the management of renal duplication associated with non-functioning
moieties and complicating ectopic ureteroceles.
Patients and Methods: 4 patients (3 girls) with renal duplication
associated with a non-functioning upper moiety and ectopic caecoureterocele
presented with recurrent urinary tract infections and bladder outlet
obstruction or prolapsed mass at the introitus. The age ranged from
1 to 5 years (mean: 2.3 years). The pathology was on the right side
in 3 patients. All patients underwent a one-stage transperitoneal
laparoscopic upper pole hemi-nephroureterectomy plus excision of ectopic
ureterocele, repair of bladder neck and extravesical reimplantation
of the ipsilateral lower moiety ureter. The laparoscopic procedure
was preceded by cystoscopic unroofing of the ureterocele and resection
of its infra-sphincteric and urethral elements, and cannulation of
the lower moiety ureter. The patient was positioned semilateral with
the ipsilateral side elevated. A 5 mm 30º scope was inserted
via a supraumbilical Step port. One more 5mm and two 3mm working ports
were then placed under endoscopic vision. After mobilisation of the
colon to expose the affected kidney, upper pole hemi-nephroureterectomy
was accomplished with the assistance of an ultrasonic scalpel. The
upper moiety ureter was completely mobilised from the lower moiety
ureter down to the point where it expanded into the ectopic ureterocele.
With traction on the upper moiety ureter the ureterocele was everted,
mobilised and excised extravesically. The resultant defect in the
bladder base and proximal urethra was repaired by interrupted 4 zero
polyglactin sutures. The lower moiety ureter was reimplanted extravesically
using 5 zero polyglactin sutures.
Results: The laparoscopic procedures were successful in all patients.
The mean operating time was 284 minutes (range: 225 - 355 mins). Mean
hospital stay was 6.3 days. Three patients recovered uneventfully
while one patient developed post-operative fever which settled with
antibiotics. There were no other procedure-related complications All
patients remained asymptomatic since surgery with a mean follow-up
time of 5.8 months.
Conclusions: Our initial experience demonstrated that radical definitive
surgery can be safely and effectively performed in a single stage
laparoscopically in the management of ureteric duplication with ectopic
ureterocele. The laparoscope allows operation on both the upper and
the lower pathologies in the same setting and further has the additional
advantage of providing a close-up view deep down in the pelvic cavity
that may not be easily accessible with traditional open techniques.
s54. LAPAROSCOPIC FOWLER-STEPHENS-PROCEDURE IN
RATS: A MORPHOLOGIC, SONOGRAPHIC AND FERTILITY STUDY
Zacharias Zachariou, MD, Patrick Günther, MD, Rainer Wunsch,
MD, Karin Gorgas, MD: Departments of Pediatric Surgery, Pediatric
Radiology, and Anatomy at the University of Heidelberg, Germany
In literature, testis atrophy after Fowler-Stephens procedure is
estimated 30%. Verification of histology of the operated testis and
fertility in humans is impossible. We simulated this peration in rats
examining testis morphology, vascularisation, inhibin B serum levels
and fertility.
Laparoscopy was performed on male rats at the age of 30 days. In
group A (5) we manipulated the right testis. In group B (12) the right
testicular vas was coagulated and dissected. In group C (12) we additionally
performed a conventional contra-lateral archiectomy. In group C the
rats were mated with female rats on the 70th day of life. At the age
of 100 days we performed duplex sonography of all testes collected
blood and the testes for histology.
All results were compaired to the data assessed in group
A and are listed in the table below. Only 2 out of 12 mailes were
fertile. (16%)
The idea for these experiments is to establish prognostic
factors for the fat of the testis. Fertile rats showed adequate vascularisation,
good histology, less fibrosis and adequate Inhibin B levels.On the
contrary bad histology and hypotrophy correlated with poor vascular
supply and infertility. Duplex sonography is a non-invasive, ethically
acceptable examination which could prove to be a good prognostic parameter
for the testis function of operated children with maldecensus testis.
s55. NEEDLESCOPIC DUHAMEL RECTOSIGMOIDECTOMY:
PRELIMINARY REPORT OF A NEW TECHNIQUE
Hock L TAN M.D., David Drake, Agostino Pierro M.D., Edward Kiely,
Miguel Guelfand Great Ormond Street Hospital for Children & Institute
of Child Heath London, U.K.
Introduction: Several minimally invasive procedures described for
treating Hirschsprung's disease are based on modifications to Soave's
operation. In our institution, the preferred procedure is Duhamel's
rectosigmoidectomy leaving a very short rectal stump. We report the
laparoscopic procedure developed by us using needlescopic (3mm) instruments
which satisfies our open surgical criteria and yet is truly minimally
invasive.
Patients and Methods: Eleven procedures were performed between November
1999 and September 2000. The first three were completed with conventional
5mm instruments. With the availability of 3mm needlescopic neonatal
instruments, all subsequent operations have been performed using these
instruments.
Results: One patient developed avascular necrosis of the pulled-through
bowel. Three had rectal septum regrowth. One patient developed intestinal
obstruction and in one, omentum herniated through a 3mm port site.
The remaining six patients had no complications. The mean operation
time was170 mins (Range 120-240mins).
Conclusion: We believe that this laparoscopic technique developed
in our institution is an attractive alternative to open surgery even
though the morbidity is currently higher than with our open technique.
Complications have occurred during our learning curve, but the last
six procedures have been uneventful. The operation time is comparable
to open surgery, and we have witnessed the benefits of rapid post
operative recovery.
s57. PERSONAL EXPERIENCE WITH 50 LAPAROSCOPIC
PROCEDURES FOR HIRSCHSPRUNG'S DISEASE IN INFANTS AND CHILDREN
Juda Z. Jona, M.D., Evanston Northwestern Healthcare, Evanston,
Illinois
During an 8 year period 50 patients with H.D. were treated by either
laparoscopic assisted pull through (6), in those with preexisting
diverting colostomy, or neonatal primary P.T. (44). Two (2) primary
attempted neonatal P.T. were converted to open resection and completion
of P.T. both for anatomic reason (1-total colon, 1-rt. transverse
H.D.) but none for operative complications.
The original clinical management and indications for primary P.T.
along with the surgical technique have not been altered since inception.
Analysis of the results showed prompt post operative recovery, absence
of enterocolitis, occasional need for anal dilitation and complete
stool continence in those > 4 years of age without any soiling
incidences. No adhesive bowel obstruction, nor appendicitis was noted
in the operated children.
Laparoscopic P.1. for H.D. is relatively easy to learn and execute,
is tolerated well by neonates and children and carries good intermediate
term results.
Summary of Data
|
Types
|
Assisted P.T.:6
Neonatal P.T.:44
Conversion to open:2
|
|
Sex
|
Male: 35
Female: 15
|
|
Age
|
Lap. Assisted: 3mo.-6yrs.
Primary P.T.:10d.o.-40d.o.
|
|
Anatomic Transition
|
Rectosigmoid:43
Lt.colon: 5
Transverse colon:1
Total colon:1
|
|
Operative Duration
|
Standard primary P.T.:140min
Conversion to open: 210m
|
|
Complications
|
EBL:<5ml
Infection: 0
E.C.: 0
|
s58. THE CHANGING FACE OF HIRSCHSPRUNG'S PULL-THROUGH
SURGERY AND COST IMPLICATIONS
MUNTHER HADDAD, M.D., CHELSEA & WESTMINSTER HOSPITAL, LONDON,
UK
AIM: To review the Hirschsprung's pull through procedures carried
out at our unit since 1994, comparing the open and laparoscopic route.
METHOD: Acombined retrospective and prospective review of case notes
and management plan was carried out to look at the two procedures.Parameters
recorded were length of procedure ,hospital stay,analgesia requirement,time
to oral fluids and feed,post operative mobilisation and morbidity
and cost analysis.
RESULTS: Thirty patients( 18 laparoscopic and 12 open)age range
12 days to 6 years had theircase notes reviewed and the data analysed.
CONCLUSION: Analysis of the data suggest that laparoscopic pull-through
is safe,cost effective and should be the procedure of choice.