IPEG 2002 ORAL ABSTRACTS

s01.ROBOTIC ENTEROTOMY REPAIR IN FETAL PIGS

Celeste M. Hollands, MD,Laramie N. Dixey, RN,
Department of Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA, Department of Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana

Introduction: The purpose of this study was to evaluate the technical feasibility of performing robotic suturing tasks in fetal pigs. Robotic procedures utilizing these tasks have been described in newborn piglets, however, difficulties with these tasks were anticipated in the smaller fetal pigs.

Methods and Procedures: Six cadaveric fetal pigs (9-11inches crown-rump length) underwent enterotomy repair using the Zeus Robotic Surgical System?. Robotic function, port site integrity, and suture time were analyzed. Suture time was the time the suture entered the field until four knots were completed intracorporeally. Suture time was then compared to suture times from previous robotic procedures. Statistical significance was defined at p<0.05 using the two-tailed student's t-test. Results: Five of six cases were completed without robotic function or port site integrity problems. The first case was aborted due to technical problems caused by traumatic enlargement of the port sites. Mean suture time was 5.4±0.96 minutes (fetal pigs, n=5) and was significantly faster than existing times:10.1±2.5 minutes (newborn piglets, n=24), p=0.0003. The faster time is likely a result of enterotomy repair being technically easier than performing an anastomosis.

Conclusion: Robotic suturing in this model is technically possible and may extend this technology to human premature infants and fetuses. Further studies using a live animal model are needed to validate feasibility.

s02. THORACOSCOPIC REPAIR OF ESOPHAGEAL ATRESIA WITH FISTULA - OUR INITIAL EXPERIENCE

Marcelo Martinez Ferro MD, Gaston Elmo MD, Horacio Bignon MD
National Children's Hospital J.P.Garrahan. University of Buenos Aires. Buenos Aires, Argentina.

OBJECTIVE: To report our personal initial experience with primary thoracoscopic repair of TEF

METHODS: Patients: 5 consecutive newborn infants with TEF. Average birth weight was 2750g (2200 to 3300g) all belonged to Spitz I group.

Technique: Patient is positioned prone and three trocars are placed (one 5mm and two 3mm). CO2 insufflation to 5mm Hg provides excellent lung retraction. Azygos vein is divided with monopolar cautery and the T-E fistula is dissected and divided using two medium-large 5mm titanium clips. Anastomosis is accomplished using 8 to10 interrupted stitches of 5/0 PDS using extracorporeal knot tying. A transanastomotic silastic tube is advanced and a 12 french chest tube is inserted via the lowest trocar site.

RESULTS: Primary correction was accomplished in all cases. No operative complications were encountered. Operative mean time was of 110 minutes (87 to 189 minutes). One patient (20%) presented a mild postoperative leak. Three patients (60%) presented anastomotic stricture that required periodical balloon dilatation with good results. Postoperative pain management and cosmetic results were significantly better than observed in open thoracotomies.

CONCLUSIONS: Although thoracoscopic primary repair of TEF seems to have great advantages, further experience and a bigger number of cases are needed in order to advance in the learning curve thus, at this stage, stricture and leakage rates still seem to be higher than observed historically.

s03. INTRATRACHEAL PULMONARY VENTILATION INCREASES THE SAFETY OF PEDIATRIC LAPAROSCOPY IN THE SETTING OF RESPIRATORY FAILURE

Amir Kaviani, MD ; Kenneth Watson, RRT; John Thompson, RRT; Christopher Muratore, MD; Alexander Dzakovic, MD; Carrie Simms, MD; Julie Fuchs, MD; Moritz M. Ziegler, MD; Jay Wilson, MD; Dario O. Fauza, MD
Children's Hospital and Harvard Center for Minimally Invasive Surgery (Boston, Massachusetts, USA).

Objective: To determine whether intratracheal pulmonary ventilation (ITPV) can prevent and/or treat the hypercarbia, high ventilating pressures, and hypoxemia observed during laparoscopy in children with severe respiratory failure.

Methods: Lung injury was induced in neonatal lambs (n=5) by repeat endotracheal saline lavage. Animals underwent establishment of CO2 pneumoperitoneum. Intraperitoneal pressures were raised from 0 to 15mmHg, at 5mmHg intervals. At each pressure interval, blood gas and hemodynamic data were recorded, along with ventilating parameters, 20 minutes after initiation of both conventional ventilation and pure ITPV, in alternating fashion. In both modes of ventilation, the FiO2, respiratory rate (RR), and inspiratory/expiratory pressures were constant. Statistical analysis was by repeated measures ANOVA, with significance set at p<0.05.

Results: On conventional ventilation, CO2 pneumoperitoneum resulted in severe respiratory acidosis at intraperitoneal pressures ¡ 5mmHg and severe hypoxemia at pressures ¡ 10mmHg. Compared with conventional ventilation, ITPV led to statistically significant decreases in pCO2 at pressures of 5 and 10mmHg and to significant increases in pO2 at 10mmHg, resolving the acidosis and hypoxemia.

Conclusions: ITPV significantly improves CO2 removal and oxygenation during CO2 pneumoperitoneum, allowing for lower ventilating pressures. ITPV increases the safety of pediatric laparoscopy in the setting of pulmonary failure.

s04. VIDEOASSISTED REMOVAL OF TWISTED NEONATAL OVARIAN CYST

A. Porreca M.D. , A.Tramontano M.D.
Ospedale Santobono, Divisione di Chirurgia d'Urgenza, Naples, ITALY

We report four cases of twisted ovarian cysts removed with laparoscopic assistance. The diameter ranged from 5 to 8 cm. In all cases the presence of an intracystic debris level was held as a sign of torsion. The age at operation varied from 3 to 10 days.

In all cases a MiniPort® was inserted in the inferior umbilical crease or contralateral flank, pneumoperitoneum was established, and a 2mm telescope MicroLap® was inserted. The cyst was aspirated percutaneously under visual control. The cyst was right sided in three cases and left sided in one. Preoperative ultrasound diagnosis was of right sided cyst in all cases. Pneumoperitoneum was evacuated to better localize the inguinal crease and a small 1.5 cm erniotomy incision was performed on the crease. The external obliquous fascia was iincised along the direction of its fibers like for a gridiron incision. Pneumoperitoneum was reestablished to allow cyst grasping under visual control through the small peritoneal opening. The ovary was totally removed in 3 cases while in one a little piece strictly adherent to the tube was left in place. In two cases the tuba involved in the torsion was removed.

This videoassisted removal of twisted ovarian cysts offers several advantages: it is simple, allows a correct diagnosis of side and a reduction of size of the cyst, adhesions of the cyst are detected, and the size and the site of skin incision offers excellent cosmetic results.

s05. MINIMAL INVASIVE OESOPHAGECTOMY AFTER CORROSIVE BURN IN CHILDREN: A CASE REPORT

Gesmundo R. ,Garrone C. ,Lonati L., Morino M., Canavese F.
Divisione di Chirurgia B Ospedale infantile Regina Margherita - Torino - Italy
Divisione di Chirurgia D'Urgenza Ospedale Giovanni Battista - Torino - Italy

BACKGROUND: Secondary mucocele is a complication of oesophageal exclusion after corrosive burns treated with oesophageal bypass The modern approach in pediatric age is to remove the damaged oesophagus during the procedure of oesophageal substitution because of risk for late malignant condition. This paper reports the complete removal by thoracoscopy of a secondary mucocele of the oesophagus in a 17 years old patient following ingestion of caustic substances in childhood.

CASE REPORT: At the age of two years the patient drank muriatic acid. Necrosis of the distal third of the oesophagus ensued with various perforations. Left latero-cervical oesophagostomy and gastrostomy were performed and the abdominal oesophagus was cut and closed with G.I.A.. The oesophagus was left in situ. One year later a Postelwheit-Galussi isoperistaltic gastric tube was created. From then on the patient has been well. A recent thoracic CT scan revealed a cystic mass 6 x 5 cm. near the hiatus. Because of the risk of a neoplastic formation the cyst was removed by thoracoscopy.

CONCLUSIONS: The procedure is feasible and safe if performed by a skill-practice thoracoscopic team. Minimally invasive oesophagectomy may reduce the morbidity of thoracotomy and allows the patient to return early to routine activities.

s06. LAPAROSCOPIC EXTRACTION OF A GIANT GASTRIC BEZOAR

Steven S Rothenberg M.D.
Presbyterian/St Lukes Medical Center Denver, Colorado

Purpose: To describe a technique for laparoscopic removal of a giant gastric bezoar

Methods: A 12 year old girl who presented with a proximal bowel obstruction was found to have a giant gastric bezoar, a small piece of which had broken loose and temporarily blocked the 3rd portion of her duodenum. Upon further evaluation and stabilization she underwent laparoscopic exploration for planned removal of the mass. Four ports, all 5mm, were used. An anterior gastrotomy was made and then a large specimen bag was placed through an enlarged umbilical port site, and the bezoar was placed in the bag. The neck of the bag was brought out of the umbilical incision and the mass was removed piece-meal. The anterior gastrotomy was closed with a running suture line.

Results: The procedure lasted 70 minutes. An NG tube was left in place and was removed on the fourth post-operative day. The patient was tolerating full feeds on day six and was discharged. There have been no post-operative complications.

Conclusion: Laparoscopic removal of an intraluminal gastric mass is a safe and effective technique. Hospital stay is not altered significantly because of the large gastric incision but pain control and cosmetic result are significantly improved.

s07. HOW TO MANAGE THE VANISHING TESTIS DIAGNOSED LAPAROSCOPICALLY? RESULTS OF AN HISTOLOGICAL STUDY.

Aceti M. R. G., M.D., La Riccia A., M.D., Riccipetitoni G., M.D.
Division of Paediatric Surgery, Ospedale dell'Annunziata - Cosenza (ITALY)

AIMS OF THE STUDY: Controversy exists about the necessity to remove the testicular nibbin in case of vanishing testis diagnosed laparoscopically. We reviewed the histologycal findings of our series and we discuss the effectiveness of a further inguinal surgery.

MATERIALS AND METHODS: In the period January 1994 - September 2001, we submitted to a laparoscopic approach for a condition of non palpable testis 82 patients, aged between 1 and 13 years; 4 of them were bilaterally affected, for a total of 86 testes investigated.

At diagnostic laparoscopy we found : 41 intraabdominal testes, 34 vanishing testes with the atretic vessels and vas deferent entering into the inguinal canal, 11 cases of intraabdominal blindended vessels. All the 34 patients with vanishing testis were treated through a minimal inguinal incision (1 cm); the residual testicular tissue was removed and submitted to histological study. The hystopathologic findings revealed : fibrosis and absence of testicular tissue in 33 speciments (97.1%), the presence of rare Leydig's cells without any seminiferous tubules in the remaning one case (2,9%).

CONCLUSIONS: We conclude that in patients with inguinal vanishing testis the removing of the residual tissue cannot be mandatory. In fact, in these cases the relief of seminiferous tubules and Leydig' cells is exceptional, so the risk of malignant degeneration can be considered remote.

s08. COMPLICATION AVOIDANCE IN MINIATURE ACCESS PYLOROMYOTOMY.

Levitt MA , Caty MG, Rothenberg SS, Tantoco JG, Chang J, Bealer JF, Brisseau GF, Glick PL
Department of Pediatric Surgical Services, Miniature Access Surgery Center, Children's Hospital of Buffalo, Department of Surgery, Miniature Access Surgery Teaching, Training, and Research Center, State University of New York at Buffalo, Buffalo, New York

Purpose. Miniature access pyloromyotomy is a well-established procedure in the management of infants with pyloric stenosis. Several studies have compared the miniature access and open approaches, and the incidence of complications is similar. The miniature access approach has benefits such as superior cosmetic results, earlier feeding, and shorter hospital stay. We describe our complications and complication avoidance techniques in miniature access pyloromyotomies. Methods. 160 infants with pyloric stenosis underwent miniature access pyloromyotomy at two centers over a two-year period. Complications and complication avoidance techniques are described. Results. Seven complications were noted. Two duodenal perforations, two incomplete myotomies, one omental evisceration, and two umbilical wound infections. The following measures were used to prevent complications; avoidance of the umbilicus if it has inadequate epithelialization, low pressure carbon dioxide insufflation, use of a retractable knife, making the ideal myotomy incision, use of a special spreader, applying slow gentle pressure while spreading, injection of air and/or methylene blue in the stomach after the myotomy, and meticulous inspection of the myotomy. Conclusions. Miniature access pyloromyotomy is an excellent procedure with avoidable complications. Key complication avoidance techniques should be employed.

s09. HAND-ASSISTED LAPAROSCOPIC COLECTOMY IN ADOLESCENTS

Klaas(N) M.A. Bax, M.D., Ph.D. , and David C. van der Zee, M.D., Ph.D.
Wilhelmina Children´s Hospital, University Medical Center, Utrecht, The Netherlands

Objective of the study: To increase the awareness amongst pediatric surgeons of the usefulness of a hand-assisted laparoscopic technique for complex operations such as colectomy in adolescents.

Methods and procedures: Two adolescents underwent colonic resection using a hand-assisted laparoscopic technique. The first patient had a left hemicolectomy with terminal colostomy and blind closure of the rectal stump for Crohn ´s disease. The second patient underwent a subtotal colectomy, ileo-neo-rectal anastomosis and protective ileostomy for ulcerative colitis. In both patients a 10cm long incision was made in a suprapubic skin crease. Through the minilaparotomy classic open surgery was performed as far as possible, which entailed also preparation of the vascularized ileal mucosal graft for inlay in the mucosectomized rectum in the second patient. For mobilization of the remaining colon a hand-assist inflatable ring (OmniportTM) was inserted in the minilaparotomy wound. Three more ports were inserted: a 11 mm one through the umbilicus for the telescope, and a 6mm port on either side of the umbilicus for the working instruments.

Results: The hand-assisted removal of the colon in both patients proved simple and lasted respectively 1 and two hours.

Conclusions: Hand-assisted laparoscopic colectomy is much simpler than a non-hand-assisted laparoscopic technique. It is especially useful in obese adolescents which is often present as an expression steroid toxicity.

s10. IS PEDIATRIC SURGICAL DEPARTMENT SUITABLE FOR QUALIFIED ENDOSCOPY TRAINING?

E. DeGrazia, G. LiVoti , M. DiPace, S. Amoroso*, M. LoCascio, C. Acierno**
*Pediatric Surgery of University of Palermo, **General Pediatric Hospital of Palermo

Introduction: The NASPGAN has defined the minimum level of procedures to perform to be considered a reliable endoscopist (100 diagnostic egd plus 50 total colonoscopy). The aim of this study is the evaluation of the number and the quality of procedures performed in a ten years time in the surgical pediatric district of west Sicily to verify the reliability of a pediatric endoscopic training program.

Methods and procedures: All the endoscopic procedures performed in the University and the General pediatric hospital in a ten years time are classified as esophagogastroduodenoscopy or rectosigmoidoscopy or total colonoscopy. The indications are compared to the end diagnosis; emergency and operative endoscopies are considered.

Results: 1757 procedures were performed.1350 egd and 407 colonoscopy, 41% of which were total colonoscopy. The indications were confirmed as reflux esophagitis and peptic disease 202, foreign body removal 78, esophageal stenosis 94, ematemesis by variceal or peptic bleeding 55 , caustic injury of esophagus 47, peg 3, recurrent abdominal pain by h.pilori or peptic disease 180, others 11, inconclusive 680. Emergency endoscopies were peformed in 13 %. The indications to colonoscopy were suspected chronic bowel disease or rectal bleeding. The 407 procedures were divided as 90 polips removal, 317 suspected inflammatory disease 89 of which confirmed the suspected diagnosis (28%).The results of endoscopic examinations were concordant to the suspected diagnosis in 49 % of cases.

Conclusions: The reported data demonstrate that even in surgical units is possibile to held an endoscopic training program. The number of procedures performed allows training one person every 3 years.The lack of sufficient number of advanced procedures as ercp,peg or variceal banding needs also a cooperative program with adult general endoscopic unit or virtual endoscopic equipment.

s11. BIGGER ISN'T ALWAYS BETTER.

Mark S. Burke BS, Joselito G. Tantoco MD, Marc A. Levitt MD, Guy F. Brisseau MD, Michael G. Caty MD, Philip L. Glick MD .
Department of Pediatric Surgical Services, Miniature Access Surgery Center, Children's Hospital of Buffalo, Department of Surgery, Miniature Access Surgery Teaching, Training, and Research Center, State University of New York at Buffalo, Buffalo, New York

Purpose. Use of smaller telescopes in miniature access surgery has the benefits of lesser abdominal wall trauma, easier intracorporeal manipulation and superior cosmesis. We hypothesized that 5mm telescopes offer sufficient visualization and clarity so that use of a 10 mm scope is rarely required, and that the use of telescopes smaller than 5mm may offer disadvantages. Methods. Total and readable fields of view were measured using 5 Stryker telescopes. 10mm and 5mm 0 deg., 10mm and 5mm 30 deg., and 2.7mm 30 deg. scopes were used at varying focal lengths. Light output readings were taken with clean and blood stained lenses. Results. Field of view measurements for the 5mm 0 degree telescope were greater than the 10 and 2.7mm scopes for each focal length (p<.05). Differences in light readings between the 10mm-0 and 5mm-0 laparoscopes were not significant when the lenses were clean but were better for the 10 mm scope when stained with blood (p<.05). No significant differences in light readings were noted between 0 and 30 degree scopes (p>.05). Light readings for the 2.7 mm scope were significantly lower than readings for the 10mm and 5mm scopes (p<.05). Conclusions. The 5mm scope provides visualization and image clarity equal to the 10mm scope. The 2.7mm scope provides inferior visualization and illumination when compared to the 5mm scope. The advantage of lesser abdominal wall trauma provided by the 2.7mm scope is outweighed by the compromised visualization and illumination.

s12. EFFICACY OF LAPAROSCOPIC MUSCLE STIMULATOR IN LAPAROSCOPY ASSISTED ANORECTAL PULL-THROUGH FOR HIGH IMPERFORATE ANUS

Tadashi Iwanaka, MD, PhD , Mari Arai, MD, PhD, Hiroshi Kawashima, MD, Sumi Kudou, MD, Jun Fujishiro, MD, Satohiko Imaizumi, MD, PhD
Department of Surgery Saitama Children's Medical Center

Purpose: To report laparoscopic findings of levator muscle and efficacy of laparoscopic muscle stimulator (LMS) in infants with high imperforate anus.

Methods: Since May 2000, 10 patients have undergone laparoscopy assisted anorectal pull-through (LAARP) for high imperforate anus (2 rectovesical fistulae, 4 rectourethral fistulae, 2 rectovaginal fistulae, 1 rectocloacal fistula, and 1 rectal agenesis). Following laparoscopic dissection of the distal rectum and division of the fistula, levator muscles in the pelvic floor were stimulated with 5mm diameter LMS. Dilatation was done by inserting a guide-wire and balloon catheter through the center of the levator muscle sling and muscle complex. Rectal pull-through and anastomosis between the rectum and anus were successfully completed.

Results: LMS showed good contraction of levator muscles and enhanced accurate midline placement of pull-through rectum. LMS was especially useful in observing weak muscles in infants with rectovesical fistula.

Conclusions: Laparoscopy and LMS offer excellent visualization of the pelvic musculature and precise tract of rectal pull-through. Fecal continence will be assessed by long-term follow-up.

s13. NISSEN FUNDOPLICATION FOR RESPIRATORY SYMPTOMS.

D. Falchetti, MD, F. Torri, MD, P. Orizio, MD , P. Salucci, MD, B. Morelli, MD, F. Braga, MD, G. Ekema, MD

Introduction Laparoscopic fundoplication, though effective on esophagitis, has unclear effects on gastroesophageal reflux (GER)-induced respiratory symptoms. Aim of this study is the assessment of this procedure on those symptoms in our patients.

Methods Between February 1995 and September 2001 44 patients underwent Nissen laparoscopic fundoplication for GER desease. 10 patients (24%) complained mostly respiratory symptoms (7 bronchopneumonia, 1 asthma, 1 laryngitis, 1 ALTE) assumed as related to GER. Diagnosis was based on clinical findings in 4 patients, on abnormal 24-hour pH-studies in 6. Eight patients underwent endoscopy with biopsy and esophagitis was found in 3. Medical trial was attempted in all patients for a mean of 12 months (1-40 months). Mean age at operation was 21 months (range 6-42). Mean weight was 11 Kg (range 3,7-20). Average follow up was 19 months (1-54).

Results There were no intra-peri-operative complications. Normalization of pH monitoring and histological studies previously abnormal was observed in all patients Respiratory symptoms were completely relieved in 8 patients, significantly improved in 2.

Conclusions GER can be responsible for respiratory symptoms without causing esophagitis. These patients need a careful preoperative assessment. Laparoscopic fundoplication is a safe and effective procedure for treatment of infants and children with severe respiratory symptoms related to GER.

s14. LAPAROSCOPIC CARDIOMYOTOMY WITHOUT FUNDOPLICATION FOR ACHALASIA CARDIA IN CHILDREN.

Munther J Haddad , Ravindra H Ramadwar, Ashish Minocha.
Department of Paediatric Surgery, Chelsea & Westminster Hospital, London, UK

Aims: Achalasia cardia has been successfully treated laparoscopically in children. However most of the surgeons prefer to perform a partial or complete fundoplication along with cardiomyotomy. We feel that fundoplication is unnecessary and contribute to persistant symptoms. The aim of our study was to evaluate our results.

Method: Since 1998, five patients were diagnosed to have achalasia cardia on barium swallow. Endoscopy was performed at the time of definitive surgery as an aid to cardiomyotomy. Four out of 5 patients underwent laparoscopic cardiomyotomy successfully without fundoplication.

Results: The median operation time was 90 minutes. The median time to oral fluids was 12 hours and the median hospital stay was 96 hours. One patient had a mucosal oesophageal perforation and hence was converted to open. The perforation was stitched with omental patch. The patient made a rapid recovery and was free of symptoms. Four out of 5 patients were asymptomatic at follow-up and one patient had occasional cough.

Conclusion: Laparoscopic cardiomyotomy without fundoplication achieves satisfactory symptomatic relief in patients with achalasia cardia. It can be performed with minimal morbidity. We feel that fundoplication (partial or complete) is not required in most of the patients with achalasia cardia.

s15. VENTILATORY AND HEMODYNAMIC MODIFICATIONS DURING LAPAROSCOPIC FUNDOPLICATION

G.Mattioli M.D., A.PiniPrato M.D. , P.Repetto M.D., S.Leggio M.D., M.Castagnetti M.D., G.Montobbio M.D., V.Jasonni M.D.
Pediatric Surgery and Anesthesiology, G. Gaslini Research Institute, University of Genova, Italy

A prospective study on anesthesiological management during pediatric lap.fundoplication is presented. 33 patients, operated on in the period 1/00-7/01, were included. Mean age was 6y(SD4.2) and weight 24Kg(SD17). 19 had gastrointestinal symptoms while 14 had respiratory symptoms. Mean duration of pneumoperitoneum and of anaesthesia was 70 min (SD21) and 116 min (SD21) respectively. To evaluate cardiorespiratory status we used an electrocardioscope, non-invasive blood pressure monitor, pulse oxymeter (partial oxygen saturation) and capnography (End-Tidal CO2, ventilation efficacy index). Moreover, after one hour of pneumoperitoneum or if necessary, a venous blood gas analysis was performed (O2and CO2 partial pressures, pH value, and bicarbonate concentration). No significant cardiovascular changes occurred. Partial O2 saturation remained within normal range in all the patients. End-Tidal CO2 increased in 5 patients (15%), 3 of whom were inhalers, but never exceeded 45 mmHg. In one patient End-Tidal CO2 persisted elevated after desufflation. Blood gas analysis showed a pH less than 7.3 in 5 patients (15%), 4 of whom were inhalers. No major complications nor need to conversion were experienced. When intra-abdominal pressure is maintained less than 12 mmHg, CO2 insufflation seems not to impair cardiovascular function, or to interfere significantly with gas exchanges. However, pneumoperitoneum reduces ventilatory function, requiring an increase in ventilation rates or volumes. The use of bicarbonates or THAM is necessary when pH drop is evident and ventilatory exchanges are not sufficient; this happens mainly in inhalers with various degrees of underlying pulmonary dysplasia.

s16. RECANALIZATION OF AN ESOPHAGEAL ATRESIA ANASTOMOSIS BY AN INTERVENTIONAL
RADIOLOGICAL TECHNIQUE

A. Alfred Chahine, MD, Maurice Poplauski, MD, Grigori Rozenblit, MD, Gastone Crea, MD, Shaker Maddenini, MD, Sabrina Falquier, MD, Karl Strom, MD, Michel S. Slim, MD
Westchester Medical Center and New York Medical College, Valhalla, NY

We present a new tool using the interventional radiology technique of transjugular intrahepatic portosystemic shunts (TIPS) to recanalize a failed esophageal anastomosis in an infant.

CASE REPORT: The 1.5 Kg patient was born at 31 weeks with esophageal atresia (EA) and tracheoesophageal fistula (TEF). Because of a long gap, division of the TEF and gastrostomy were performed. Two months later, she underwent a delayed primary anastomosis. The contrast study showed the proximal pouch to be connected to a false lumen. Endoscopic recanalization was unsuccessful. Under fluoroscopic control, the needle used for TIPS was introduced through the gastrostomy, pushed through the membrane of the false channel and grabbed by a basket introduced through the mouth. A wire was left in place. The lumen was sequentially dilated using pneumatic and bougie dilatations to a size 30 Fr. She required 9 dilatations over a course of 2 months. She expired two months after the last dilatation of unrelated sepsis. At the time of her death, there was no clinical evidence of stricture.

DISCUSSION: Obliteration of the anastomosis by a false lumen is a rare complication of EA repair. Spontaneous fistulization did not occur in this patient. Applying this technique, we were able to recanalize the lumen and dilate it to an adequate size, sparing her a third thoracotomy. This technique could be applied to cases of severe strictures where a lumen could not be established by standard methods.

s17. FUNDOPLICATION IS RARELY NECESSARY FOLLOWING LAPAROSCOPIC GASTROSTOMY EXCEPT IN
THE NEUROLOGICALLY-IMPAIRED CHILD.

David A. Partrick, M.D. , Denis D. Bensard, M.D.
Department of Pediatric Surgery, The Children's Hospital, University of Colorado

Introduction: Laparoscopic gastrostomy is a safe and effective technique. Patients may have evidence of uncomplicated gastroesophageal reflux (GER), leading some to advocate prophylactic fundoplication at the same time as gastrostomy. The purpose of this study was to determine if uncomplicated GER necessitated subsequent fundoplication.

Methods: From 1997 to 2000, 45 children referred for feeding access with no evidence of esophagitis/stricture, lung disease, or apnea, were offered laparoscopic gastrostomy. The operation was performed utilizing a two-port technique. Postoperatively, children failing medical management of GER or developing complications of GER were treated with fundoplication.

Results: Indications for feeding access included neurologic impairment(12), aspiration(10), trauma(7), malignancy(6), failure to thrive(6), and cystic fibrosis(4). Mean age of the children was 5.7+-5.5 years with a mean weight of 11.2+-6.5 Kg. Eighteen children(40%) had clinically-suspected or radiographically-proven GER prior to laparoscopic gastrostomy. Postoperatively, 5 patients(11%) subsequently underwent fundoplication. Three of these five patients were neurologically impaired.

Conclusions: Although fundoplication became necessary in 11% of all patients, this was done in only 6% of neurologically normal children and 25% of neurologically impaired children. Therefore, in the absence of absolute indications, fundoplication concomitant with laparoscopic gastrostomy is unnecessary.

s18. LONGTERM FOLLOW-UP AFTER LAPAROSCOPIC TOUPET FUNDOPLICATION IN CHILDREN WITH
ATYPICAL SYMPTOMS OF GASTROESOPHAGEAL REFLUX

Mario Mendoza-Sagaon MD, Karen Herreman-Suquet MD, Guillaume Cargill MD, Daniel Caillot MD and Philippe Montupet MD
Clinique Chirurgicale de Boulogne Billancourt. Paris, France.

The aim of this study was to evaluate the long-term follow-up in patients with atypical symptoms of gastroesophageal reflux (GERD) submitted to a laparoscopic Toupet fundoplication (LTF). A questionnaire was mailed to patients operated between 06/93 to 01/00. Questions included: symptoms before and after surgery; medication; re-operations; postoperative (PO) X-rays, pHmetry, esophageal manometry and endoscopy; recurrence of symptoms; quality of life, esthetics, and psychological outcome. 94 questionnaires were mailed. 39 boys and 31 girls responded. Mean age was 8.3 yrs (8m-25yrs). Mean follow-up was 3 yrs (6m-7yrs). 67% reported a notorious decrease of symptoms, 51% reported vomit, nausea, diarrhea or hick-ups within the first PO weeks. 88% suspended antireflux medication after surgery. None of them have been re-operated. 74% have had a normal PO pHmetry, Upper GI, or manometry. 84% are free of symptoms. A good to excellent result was reported in 94% regarding esthetics, 81% in PO psychological status, 94% in the quality of life and 91% in the general result to this procedure. These results show that LTF is an excellent surgical option for children suffering from GERD with atypical symptoms.

s19. LAPAROSCOPIC INTERVENTION OF INTRA-THORACIC STOMACH IN INFANTS.

Makoto Yagi,M.D.,Ph.D. , Keisuke Nose,M.D., Katsuji Yamauchi,M.D., Takashi Nogami,M.D., Hideki Yoshida,M.D., Harumasa Ohyanagi,M.D.,Ph.D.
Department of Surgery II, Kinki University, School of Medicine, Osaka-Sayama, JAPAN

[Aim] Intra-thoracic stomach is an uncommon condition that is divided into three types. The aim of the paper is to describe our experience of four infants with intra-thoracic stomach repaired by a laparoscopic operation.[Subjects] The age of the patients on diagnosis ranged from thirteen days to one year and two months.The symptoms were severe anemia due to gastric bleeding in one case and failure to thrive in two cases.The other case was neurologically impaired.The diagnosis was confirmed by gastrographin study. Preoperative nutrition was maintained via oral in two cases and via naso-duodenal tubing in the others.[Operation] Laparoscopic reduction of the stomach was easily performed in all.Oro-gastric tubing served to keep the stomach in the abdomen.The type of hiatal hernia was paraesophageal hernia in one case and sliding hernia in three. In the case of sliding hernia, the esophago-phrenic membrane was very thick, so the membrane was completely removed to make sure the crus. After closing the crus, 360-degree fundoplication was performed in all cases. In paraesophageal hernia, the cuff was sutured to the crus to prevent relapse.Gastrostomy was made in one case of neurological impairment.[Results] Follow-up term is from one month to three years. No relapse was seen.Without neurologically impaired case, the growth and the development of the patients are within normal limit.[Conclusion] Laparoscopy is feasible and effective for the treatment of intra-thoracic stomach.

s20. LAPAROSCOPIC GASTROSCOPY ASSISTED VENTRAL THAL HEMIPLICATION AS REDO-PROCEDURE IN RECURRENT GASTROESOPHAGEAL REFLUX

Klaus Schaarschmidt , A Kolberg-Schwerdt, M Lempe, C Neumann
Helios-Centre of Pediatric Surgery, Berlin-Buch, Germany

Objectives: Being satisfied with open Thal particularly for handicapped children with impaired esophageal motility we performed gastroscopy assisted lap. Thal as routine since 3/1993 in Berlin-Buch and since 1998 for recurrences. To evaluate the procedure patients were followed prospectively.

Methods: Preoperatively (6, 24, 60 months) patients had oesophageal pH-monitoring, oesophagogastroscopy, and most upper GI series/szintigraphy. Surgery was indicated by convincing history of vomiting, aspiration, failure to thrive despite maximal medication >6 months plus massive reflux (pH < 4, >20% of time) plus histological esophagitis, three had peptic stenosis.

Results: Out of 54 lap. Thals seven handicapped children got gastroscopy assisted laparoscopic redo-Thal after 1-5 failed open Nissen fundoplications and one Thal. In all, satisfactory Thal wrap could be confirmed by intraoperative gastroscopy, but two conversions were necessary for esphageal perforation and inadequate vision. After 5-32 months all children are clinically free of symptoms, 5 have a normalized ph study (< 2 %) and only 2 have borderline ph studies (4.2 and 5 % Reflux) after 6 months. Reflux index has dropped from a mean of 52.8 % ± 23.1% (range 17-81,8%) preoperatively to 2.1 % ± 2% (range 0,1-5%) postoperatively (6-24 months).

Conclusions: Gastroscopy assisted lap. Thal hemiplication is a safe and effective new technique for redo procedures even in small children and after multiple open procedures.

s21. ITALIAN MULTICENTER SURVEY ON LAPAROSCOPIC GASTRO-ESOPHAGEAL REFLUX SURGICAL TREATMENT

G.Mattioli M.D. , M.Lima M.D., C.Esposito M.D., M.Messina M.D., L.Montinaro M.D., G.Cobellis M.D., L.Mastoianni M.D., M.G.R.Aceti M.D., D.Falchetti M.D., V.Jasonni M.D.,
Pediatric Surgery - G.Gaslini Research Institute - University of Genova - Italy

The authors present the experience of 8 Italian pediatric surgical units on the laparoscopic treatment of gastro-esophageal reflux (GER). Inclusion criteria were: fundoplication performed after 1/98 in children younger than 14 years, with a minimum follow-up of 6 months. 288 children were included. Mean age was 4.8 years (3m14y). Esophagitis was the main symptom in 182 cases, asthma in 53, respiratory infections in 80. Hiatus hernia was present in 84 and associated diseases in 101 (neurological impairment in 73 and previous TEF in 12). Esophageal pHmetry was performed in 89%, endoscopy in 74%, upper GI tract meal X-ray in 94%, gastro-duodenal transit time in 12% and respiratory tract endoscopy in 11%. In 93% of cases the procedure was completed by laparoscopic approach. A Nissen fundoplication was done in 25%, a floppy Nissen in 63%, a Toupet in 1.7% and other procedures in 10% of patients. Sectioning of the lesser omentum was routinely performed in all the cases of 4 centers and no resection of the short gastric vessels in 6 centers. Naso-gastric tube was maintained for at least 24 hours in 6 centers. Gastrostomy was always associated, if neurological impairment or feeding disorders were present. Mean follow-up was 15 months (6-54); 17 children (6%) needed re-operation because of stricture of the wrap or recurrence of GER. The experience of the different centers showed a great variability in indication and procedure with a similar outcome. Details will be discussed.

s21a. THORACOSCOPIC LOBECTOMY FOR PRENATALLY DIAGNOSED LUNG LESION

Craig T. Albanese, M.D., KuoJen Tsao, M.D., Roman M. Sydorak, M.D., Hanmin Lee, M.D.
Fetal Treatment Center, Division of Pediatric Surgery, University of California, San Francisco, San Francisco, California

Objective: Few lung lesions, now diagnosed with increasing frequency antenatally, lead to in utero demise or require prenatal intervention. For patients delivered at term, we present our early series of surgical management using modern minimal access techniques.

Methods: Retrospective chart review performed at single institution from June 1999 to October 2001. Patients with prenatally diagnosed lung lesion not requiring prenatal intervention comprised study group (n=12; 8 males, 4 females). All patients underwent elective postnatal lung mass excision, and clinical characteristics and perioperative course were analyzed.

Results: All lesions demonstrated size regression prenatally. No neonate was symptomatic at birth. CT scan confirmed diagnosis despite normal chest radiograph at birth in all. All patients underwent elective thoracosopic lobectomy at mean age of 6 months (range 3-15 mos). Mean operating time, 110 min. Ten were cystic adenomatoid malformation, 1 extralobar sequestration, and 1 intralobar sequestration. Eleven were left-sided (10 lower lobe); 1 was right-sided (lower lobe). There were no intraoperative or postoperative complications. Average hospital stay was 38 hours.

Conclusion: Accurate prenatal diagnosis and surveillance of fetal lung lesions has resulted in a group of postnatally asymptomatic patients who are candidates for elective thoracoscopic resection. These lesions can be safely removed using modern minimal access techniques.

s21b. LAPAROSCOPIC ADRENALECTOMY IN CHILDREN

Kelly A. Miller MD, Craig T. Albanese MD, Diana L. Farmer MD, Michael Harrison MD, George W. Holcomb III MD
Children's Mercy Hospital, Kansas City, Missouri, USA and University of California, San Francisco, San Francisco, California, USA

PURPOSE: Laparoscopic adrenalectomy is being recognized as the new gold standard in the management of adrenal pathology in adult patients. Few reports have described the use of this technique in pediatric patients.

METHODS: A bi-institutional retrospective chart review of all patients undergoing laparoscopic adrenalectomy between January 1997 and November 2000 was performed.

RESULTS: Fifteen laparoscopic adrenalectomies were performed in ten females and five males with a mean age 9 yrs (range, 3-16 yrs). Pathology was isolated to the left adrenal gland in 11 patients and right gland in 4 patients. The average duration of operation was 103 minutes, the estimated blood loss was less than 30 ml in all cases, and the mean size of the adrenal lesions as 4.6 cm in greatest dimension. The mean length of postoperative hospitalization was 35 hours with average length follow-up of 23 months. There were no intraoperative complications. However, the one patient with carcinoma had tumor thrombus in the adrenal vein and this procedure was converted to an open operation for renal vein tumor thrombectomy.

CONCLUSIONS: Laparoscopic adrenalectomy can be performed safely and effectively with a short postoperative stay and minimal blood loss in children. We believe it should become the approach of choice for excision of select pediatric adrenal pathology.

s21c. CERVICO-MEDIASTINOSCOPIC THYMECTOMIES IN CHILDREN

Olivier Reinberg (1), Philippe Montupet (2), Helène Martelli (2)

Introduction: After having performed 2 video-assisted thymectomies in children in 1997 we changed for a totally closed approach in 3 additional cases, so-called cervico-mediastinoscopy.

Method: Children ranged from 5 to 15 years of age. All but one suffered from myasthenia gravis. Through a 1 cm medial substernal incision the thymic lodge is entered and a pneumodissection is performed. Two lateral 3 mm ports allow dissection of the thymus and its total removal.

This approach provides a very good view of the vascular bundles. The freeing of the gland from the innominate vein is easy and leads to a wide view of the mediastinum, thus helping to ensure entire removal of the thymus. An extensive dissection can be done through this approach as is evidenced by the position of the drain along the pericardium, when being used. No complication occured, but a significant hypotension in 2 patients, resolved with adequate fluid infusion. Children were discharged the day after surgery and returned to school within the same week. They remain free of symptoms at follow up from 50 to 5 months later.

Conclusion: This procedure, which differs from latero-thoracic video surgery previously described in adults, avoids a sternotomy, gives a wide and nearly micro-surgical view of the thymic area and of the surrounding structures and provides as good or even better proof of total removal of the thymus.

s21d. CLINICAL RESULTS IN THORACOSCOPIC SURGERY USING AN ELECTROTHERMAL BIPOLAR VESSEL SEALER

Steven S Rothenberg M.D. , John T. Bealer M.D.,Jack H.T. Chang M.D., Ned Cosgriff M.D.
Presbyterian/ St Lukes Medical Center Denver, Colorado

Introduction: Advanced thoracoscopic surgery requires a method of obtaining reliable hemostasis and lung sealing to ensure successful outcomes. The recent introduction of bipolar sealing technology has made it possible to seal arteries and veins up to 7mm in diameter safely and effectively through a 5mm port. Chronic animal studies have demonstrated the effectiveness of the vessel-sealing device on both the pulmonary vasculature and the lung parenchyma. We have previously reported on our initial experience with this device in pediatric MIS surgery and we now report on its use in advanced thoracoscopic procedures.

Methods: From September 1999 to September 2001, 14 patients, ranging in age from 2 months to 18 years, and weight from 4.2 to 78 Kg, underwent thoracoscopic lobe resections, (2 upper, 12 lower), using the bipolar vessel sealing system as the primary method for hemostasis, vessel occlusion, and parenchymal sealing. Vessels completely sealed by the system include the inferior pulmonary vein and the pulmonary artery to the lower lobe. The device was also used to seal and divide lung parenchyma when the fissure was incomplete.

Results: Operative times ranged from 50 to120 minutes. There were no technical failures of the device to achieve hemostasis and lung parenchymal seal was complete in every case (no air leak). As experience was gained no other hemostatic modalities were necessary or used, even on the main pulmonary vessels. The instrument worked well as a dissecting tool limiting the need to exchange instruments, and blood loss was minimal in all cases. The dissection was carried out completely through the trocars with the largest port site necessary being 5mm in the later cases. Mini-thoracotomy was not required in any case. Hospital stay ranged from one to 4 days.

Conclusion: Continued experience with the laparoscopic bipolar vessel-sealing device in thoracic surgery indicates that it is effective for dissecting and permanently sealing vessels and lung tissue commonly encountered during thoracoscopic lung resection. It's 5mm size eliminates the need for placing larger trocars for the introduction of endoscopic staplers, clips or other devices, and allows these procedures to be performed even in small infants.

s22. LAPAROSCOPIC APPENDICECTOMY: A SUITABLE CASE FOR THE TRAINEE?

Atul J Sabharwal M.D, Gordon A MacKinlay M.D., Fraser D Munro M.D.
The Royal Hospital for Sick Children, Edinburgh, Scotland

Objective: To assess the impact of laparoscopic appendicectomy (LA), as an alternative to open appendicectomy (OA), has had on Surgical Training in our unit. In particular, can LA be safely performed by trainees under supervision.

Methods: A prospective 3 year review (1998-2000) was undertaken of all appendicectomies in patients with suspected appendicitis. LA was offered if the Consultant on-call had laparoscopic training. A record was kept of grade of operator, mode and length of procedure, nature of appendix and any complications.

Results: Over the 3 years the percentage of LA vs OA were 27/73%, 31/69% and 32/68%. The main operator in LA was either a Consultant or SpR, the percentages from 1998 to 2000 being 66/34%, 31/66% and 46/54%. Median lengths of LA by Consultant were 55, 50 and 51 minutes and for SpRs 45, 40 and 53 minutes. Of the OA cases SHO(III)s carried out 49, 42 and 43% each year while SHO (I) grades carried out 23, 15 and 38% of cases. There were no significant differences in complication rates either by operator grade nor mode of procedure.

Conclusions: In our unit over half LA cases are now carried by trainees under Consultant supervision. There is a minimal increase in operation duration compared to OA performed by the same trainees but no increase in complications as compared to LA carried out by a Consultant or OA. We believe LA is the ideal operation for training in paediatric laparoscopic surgery.

s23. ONE-TROCAR VIDEOASSISTED APPROACH TO MECKEL'S DIVERTICULUM IN CHILDREN

G.Cobellis,MD, L.Mastroianni,MD, G.Muzzi,MD, A.Zangari,MD, A.Cruccetti,MD, M.Zamparelli,MD, G.Amici, MD and A. Martino, MD
Pediatric Surgery Unit, Salesi Children's Hospital, Ancona, ITALY

Introduction The authors report their experience with a videoassisted technique for Meckel's diverticulum diagnosis and treatment using only one trocar.

Methods and procedures Between January 1998 and June 2001 transumbilical one-trocar ileal exploration was performed in 5 patients with intestinal bleeding. Meckel's scan had been performed in all patients. Mean age was 6.8 years ( range 6 months- 12 years). An Hasson 10 mm ballooned trocar was placed in an open fashion through the umbilicus and pneumoperitoneum was established to a pressure of 12 mmHg. Using a 10 mm operative telescope terminal ileum was grasped with an atraumatic instrument and exteriorized through the umbilicus. Ileal exploration and diverticulum treatment was performed using traditional methods outside the abdominal cavity.

Results Radionuclide scan was positive in only 1 patient. Overall in 2 patients a Meckel's diverticulum was found at videoassisted transumbilical ileal examination and intestinal resection and anastomosis performed (mean operative time 65 minutes). No complications were observed at a maximal follow-up of 36 months.

Conclusions This technique is a safe and effective mininvasive procedure for both diagnosis and treatment of Meckel's diverticulum in children.

s24. LAPAROSCOPIC CECOSTOMY BUTTON PLACEMENT FOR MANAGEMENT OF FECAL INCONTINENCE IN CHILDREN

Aydin Yagmurlu M.D. , Carroll M. Harmon M.D., Ph.D., Ketih E. Georgeson M.D.
Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama 35233, USA

Introduction: The antegrade colonic enema (ACE) procedure offers a surgical solution for many children with chronic constipation and encopresis associated with Hirschsprung's disease and anorectal malformations. This study's purpose was to evaluate the safety and efficacy of a new laparoscopic technique for cecostomy button placement (LCBP) to allow ACE treatment.

Methods and Procedures: Charts of children with encopresis undergoing LCBP between 1999 and 2001 were reviewed. Patient's age, weight, primary diagnosis, operation time, hospital stay, associated complications, follow-up duration and outcome were investigated. The surgical technique (modification of that described for primary gastrostomy button placement) utilized a 'U stitch' method.

Results: Of the five patients between 4 to 12 years (mean 7.8+-1.56) old and weighing 15 to 44 kg (mean 25.8+-5.16)-- 3 had Hirschsprung's disease and 2 had anorectal malformations. LCBP was successful in all with no intra-operative complications. The mean operative time was 32.2+-2.03 minutes. Hospital stay was 2 to 5 days (mean 3.8+-0.58). Two patients had granuloma formation, which responded to topical therapy. The button was changed twice in one patient due to mechanical malfunction. Mean follow-up was 12.6+-4.39 months (range 5 to 29). One or two daily antegrade enemas resulted in continence with minor soiling in all.

Conclusion: LCPB is safe and efficacious in the treatment of overflow incontinence in children.

s25. LAPAROSCOPIC ASSISTED SURGERY FOR CROHN'S DISEASE

Robertine van Baren, M.D. , Wim G. Van Gemert, Ph.D.,
Pediatric Surgical Center Amsterdam, locations Emma CH AMC and Free University MC, The Netherlands

Objective: In 1993 the first laparoscopic assisted ileocecal resections in adults were described. In 1999 we started this procedure in adolescents. Feasibility and postoperative course were investigated.

Methods: From July 1999 till October 2001, 12 consecutive patients underwent laparoscopic assisted surgery for Crohn's disease. The procedures, operative time, postoperative complications and hospital stay as well as outpatient follow-up were reviewed.

Results: There were 5 girls and 7 boys: mean age 15 yr (range 10 yr -17 yr), mean body weight 46 kg (range 30 kg - 65 kg). Presenting symptoms consisted of persistent abdominal pain (10), growth retardation (8) and osteoporosis (5) due to medication. One patient had cystic fibrosis. All 12 contrast studies were abnormal, showing a stenosis in 7. All 12 patients underwent an ileocecal resection, one patient had a combined partial resection of the jejunum. Three resections extended to the right colon. One of these patients had an ileosigmoid fistula causing conversion to an open procedure and in one patient with a stenosis in the left colon an ileostomy was performed. The mean operative time was 2.24h(range 1.27h - 3.25h). There were 2 postoperative complications: a gastric dilatation and, after the open procedure, an abdominal abscess, that caused readmission and was managed by ultrasound guided drainage and intravenous antibiotics. The mean postoperative hospital stay was 5 days (range 4d - 8d). Three late readmissions occurred for exacerbation of Crohn's disease, leading to a laparoscopic assisted subtotal colectomy in one. The mean follow-up was 14 months (2m - 27m). There were no cicatricial hernias. The cosmetic results were excellent.

Conclusions: Laparoscopic assisted surgery for Crohn's disease is feasible, without major complications. The adolescents were very satisfied with the excellent cosmetic result.

s27. GETTING RESIDENTS IN THE GAME: AN EVALUATION OF GENERAL SURGERY RESIDENTS' PARTICIPATION IN PEDIATRIC LAPAROSCOPIC SURGERY

Gerald Gollin, MD and Donald Moores, MD
Loma Linda University School of Medicine and Children's Hospital Loma Linda, CA, USA

Objective: In a large children's hospital, we evaluated general surgery residents' experience with pediatric laparoscopic procedures and the impact of their participation on patient outcome. Methods: The records of all children who underwent laparoscopic appendectomy, splenectomy, fundoplication or pyloromyotomy were reviewed. The level of participation (surgeon, first assistant or none) by general surgery residents in each of these operations was determined. Outcome was assessed for these procedures in terms of intraoperative and postoperative complications. Results: The following table summarizes the frequency of resident participation in pediatric laparoscopic procedures and indicates any significant adverse outcomes in the overall group.

Operation	Total operations	Resident as surgeon	Adverse outcomes (level of surgeon)
Appendectomy	174	163 (94%)	1 wound infection (R2) 1 phlegmon (R4) 2 intra-abdominal abscesses (R2)
Splenectomy	36	35 (97%)
Fundoplication	104	78 (75%)	5 cases of recurrent reflux requiring re-op: (3 R4, 2 attending) 1 esophageal injury (R4)
Pyloromyotomy	97	72 (74%)	1 incomplete myotomy (R2) 1 mucosal injury (R4)

Conclusions: We have demonstrated that well-supervised general surgery residents can perform common, pediatric laparoscopic operations with excellent results. Although it is essential for established pediatric surgeons and fellows in pediatric surgery to acquire expertise in minimally invasive surgery, once they have confidence in their own skills they may safely permit qualified general surgery residents to perform laparoscopic procedures in children.

s28. LAPAROSCOPIC SWENSONS PULLTHROUGH FOR HIRSCHSPRUNG'S DISEASE - AN OPTIMAL APPROACH FOR BOTH PRIMARY AND SECONDARY PULLTHROUGH PROCEDURES

Rajendra Kumar, Athol Mackay, Peter Borzi
Mater and Royal Children's Hospital, Brisbane, Queensland, Australia 4102

Background/Aim: Primary laparoscopic assisted endorectal colonic pull though has been widely described and accepted in recent years with proven advantages over the traditional open approach in Hirschsprung disease (HD). In recent years there has been an increasing trend to apply the technique to a purely perineal endorectal technique. We have been performing Laparoscopic Swensons (LSw) pull through both for primary and secondary procedures as well as seromuscular biopsy/ frozen section for siting of stoma To evaluate its use we report our experience with both primary and secondary laproscopic swenson's pull through for HD in children.

Methods: A retrospective review of all children who underwent laparoscopic procedures for HD in the last six years. A three port technique allowed the transition zone to be identified with seromuscular biopsies. The distal bowel is devascularised with diathermy and mobilized to deep into the pelvis. This was followed by anal mobilsation of the ganglionated bowel and perineal anastomosis. Follow - up was performed in all patients.

Results: Forty-two children underwent a laparoscopic pullthrough for HD( 19 primary neonatal).

Of these, LSw was performed in 29 children, which included 16 primary neonatal Swenson procedures. The median weight of this group of neonates was 3.4 kg at the time of surgery. Secondary Swenson's pull through procedure was performed in the remaining 13 children which included three patients with total colonic HD who underwent laparoscopic total colectomy and swenson's pull through. The median operating time was 105 minutes (range: 66 - 175 minutes). The median time to commence full diet was 48 hours (range: 24 - 86 hours) . No patient required conversion to open. Post operative ileus was noted and self limiting in three patients. There was no difference in operative time for primary as well as secondary pull through although it was easier to perform as a primary pull through. Enterocolitis was noted in two patients in the Swenson's group . Follow-up was between 6 month to six year with a median of three years. Majority of the patients have excellent continence . There are 2 children with Laparsocopic MACE who now are soil free

Other procedures included Laparoscopic assisted Soave procedure (n = 8), Laparoscopic Duhamel (n = 3) and laparoscpic colectomy with stoma (n = 2).

Conclusions: Swenson's procedure seems to be the most suitable procedure for laparoscopic management of biopsy proven HD in children, both for neonatal one stage primary pull through and secondary pull through procedures.

s30. COMPLICATIONS AND CONVERSIONS OF PEDIATRIC LAPAROSCOPIC SURGERY: THE ITALIAN MULTICENTRIC EXPERIENCE WITH 2305 PROCEDURES

Esposito C MD PhD 1 , Mattioli G MD 2, Monguzzi GL MD 3, Montinaro L MD 4, Riccipetiotoni G MD 5, Messina M MD 6, Pintus C MD 7, Lima M MD 8 , Settimi A MD 9, Esposito G MD 9, Jasonni V MD 2

Aim: Reports of complications during pediatric laparoscopic procedures are seldom found in the international literature.

Methods: Between 1996 and 1999, during a 4-year-period the data on 2305 procedures performed in 11 italian centers of pediatric surgery were collected. The data from two centers, for a total of 616 laparoscopic procedures, were largely incomplete, and were thus excluded from the study. We analyzed the data from 9 centers only, for a total of 1689 laparoscopic operations. The type of operations performed ranged from basic laparoscopic procedures such as varicocelectomy and cryptorchidism, to advanced laparoscopic procedures such as splenectomy, total colectomy, and esophageal achalasia.

Results: We recorded 79 complications ( 4.6 %) in our series. In 57/79 cases (72.2%) the problem was solved by laparoscopy. Twenty-two cases (27.8 %) required conversion to open surgery.There was no mortality in our series. At a maximum follow-up of 4 yrs, all children were alive and had no problems related to the laparoscopic complications.

Conclusions: The authors believe that the routine use of open laparoscopy in pediatric patients is a key factor to help avoid complications. Moreover the surgeon's laparoscopic experience, the correct indications for laparoscopic surgery, and the verification of the laparoscopic equipment before surgery, are also important rules to follow to reduce the incidence of complications.

s30a. LAPAROSCOPIC POCKET SPLENOPEXY (LAPS) FOR WANDERING SPLEEN A NEW TECHNIQUE

Marcelo Martinez Ferro , Gaston Elmo, Lisandro Piaggio
National Children's Hospital J.P.Garrahan. University of Buenos Aires. Buenos Aires, Argentina

OBJECTIVE: To report a new technique for splenopexy in cases of wandering spleen.

METHODS: Case Report: A 4 years old boy consulted for recurrent abdominal pain and a palpable mass. Wandering Spleen diagnosis was achieved by ultrasound. For Laparoscopic Pocket Splenopexy (LAPS) an extraperitoneal space was created using an inflatable balloon device. Using a 3 ports approach, the spleen was introduced and fixated inside the created pocket.

RESULTS: Operative time was 90 minutes and the patient was discharged 24 hs after the procedure. Recovery was uneventful. Postoperative Doppler ultrasound follow-up shows a well fixated spleen in the left upper quadrant. The patient remains without symptoms 1 year after the procedure.

CONCLUSIONS: LAPS is a easy and reproducible technique that can be used for definitive treatment of wandering spleen in children.

s30b. THYMECTOMY: PURE THORACOSCOPY VS MINI-THORACOTOMY VIDEO ASSISTED

Francisco Berchi MD, Maribel Benavent MD, Jesus Cuadros MD, Juan Anton-Pacheco MD
Department of Pediatric Surgery, Hospital 12 de Octubre University Complutense Madrid/Spain

Video-assisted thoracoscopic surgery became an important tool in the surgical treatment of various diseases.Currently many interventions which routinely required thoracotomy can be performed by a VATS safely and with excellent results. This includes thymectomy for myastenia gravis,thymomas,thymic cysts,hyperplasia,etc. In most cases, myastenia gravis and thymoma require complete removal of the thymus gland and resection of the pericardial fatty tissue.There is some debate, however, over which surgical approach is best for thymectomy. The left axilla was exposed with the arm in an extended position. 3 thoracos-copic ports were placed in an inverted triangle position in the left axilla with a 5mm, 30 degree angled camera port at the posterior axillary line in the 4th intercostal space and 2X5 mm operating ports at the anterior axillary line in the 3rd and 5th intercostal spaces. In all cases the mediastinum was accesed

through the left chest. A pneumotorax was evaluated and eventually chest tubes were used. There was no conversion to open technique, no complication, no postoperative ventilation and no mortality. The thymus must be dissected by gentle traction and separated from pericardium,brachiocephalic vein and aorta behind the sternum. The thymus is removed with a complete

resected specimen. The procedure results in a shorter hospital stay, quicker recovery,better cosmetic and significantly reduces the overall cost to health care.

s31. INTRAVESICAL URETERAL REIMPLANTATION ACCORDING TO COHEN AND USING LAPAROSCOPIC TOOLS PRELEMINARY EXPERIENCE IN CHILDREN.

Valla J.S., Almohaidly M., Lembo M.A., Carfagna L., Steyaert H.
Pediatric Surgery Fundation Lenval Nice, France

Introduction : Previously described minimally invasive surgical techniques for treating vesicoureteral reflux include laparoscopic extravesical reimplantation according to Lich-Gregoir and Trigonoplasty according to Gil-Vernet. The former needed a transperitoneal approach and the latter has a significant failure rate. In order to perform with minimally invasive technique, the same technique we use with open surgery, we have performed intravesical ureteral reimplantation according to Cohen with laparoscopic tools. A video illustrates the technique (4').

Methods : Three children ages 4 to 6 years undervent transtrigonal reimplant (one unilateral, one bilateral and one with duplication). Three 5mm post were placed percutaneously into the bladder for 5mm 30° telescope and two operating devices. The bladder is insufflated with a 8mm Hg CO2 pressure. The air leak through the urethra is avoided by the balloon of a Foley catheter. All the steps of the procedure are realized intravesically : dissection of the ureter, creation of the submucosal channel, resection of the distal part of the ureter and ureterovesical anastomosis with 6/0 absorbable suture. No ureteral catheter was left in place, no drain in the perivesical spaces, but a Foley catheter during the first two postoperative days.

Results : Operative time ranged between 2 and 3,5 hours. The hospital stay for these first cases is 3 days. Post-operative hematuria is reduced to one day. We have had no postoperative complication but the follow up is very short and no patient have yet had their six months following studies with VCUR, ultrasound and cystography.

Discussion : This endoscopic COHEN reimplantation is feasable and because the main steps are similar to open reimplantation the same long term results could be expected. However many technical problems remain : the working space is narrow, the potential extravasation of CO2 into the extravesical space, the closure of trocart sites in the bladder, the necessity to use specialy designed trocar to avoid inadvertent removal (not available in 3mm) etc...

Conclusion : Minimally invasive transtrigonal reimplantation is technically feasable. Potential advantages include reduced abdominal wall trauma and, above all, reduced bladder wall trauma. In the future, robotic technology especially the use of surgical telemanipulators may have an increasing role in the endoscopic treatment of pediatric vesicoureteral reflux.

s32. OUR EXPERIENCE IN THE MANAGEMENT OF PROBLEMS IN LAPAROSCOPIC PYELOPLASTY FOR HYDRONEPHROSIS IN CHILDREN

K.Selvarajan MCh ,M.Ramalingam Mch, M.G.Pai MCh,
K.G.Hospital and Research Institute, Coimbatore,India

Laparoscopic management of hydronephrosis in children has been tried in our centre as an alternative to open pyeloplasty. There are certain issues in laparoscopic pyeloplasty like position of the patient, placement of ports, how to expose the PUJ,stenting(the timing, the type of stent and from where and how to place the stent), the site and type of drain.

Materials and methods

14 cases of laparoscopic pyeloplasty was done in children between the ages of 3 months to 11 years. The time taken was between 340minutes maximum and 136 minutes at the lowest. The difficulties encountered were analysed and modified (a). Position: Instead of true lateral position,a pad or slight increase in kidney bridge will open the space between pelvis and costal margin for better working. (b)Ports: selected on the basis of PUJ level was helpful while suturing than based on hilum of the kidney. (c) Colonic mobilisation: can be avoided if pelvis found to be distended medial to colon and transmesocolonic approach to pelvis is done. (d)Stenting: RGP and keeping the guide wire and stent just below PUJ before pyeloplasty. It helps to keep this stent from below especially just before completion of anterior layer of pyeloplasty.(e)Drain:a corrugated flank drain found to be draining well due to its dependent position.

Results

Laparoscopic pyeloplasty is a technically highly demanding surgery. It is time consuming due to various factors. Our experience reveals that, apart from learning curve, once the difficulties were overcome by modifications explained above, the length of surgery grossly has come down from 340 minutes to 136 minutes. Not only the time but also the real difficulties encountered earlier were overcome and the ease of doing pyeloplasty has been standardised. Effective drainage in the form of flank drain helped the incidence of paralytic ileus in many cases.

Conclusion

Laparoscopic pyeloplasty just like every technique needed modifications to give better results and it should be done easily by all. In that way, the modifications which are explained above were really useful in performing pyeloplasty easily thereby reducing the difficulties to a great extent as well as minimising the overall time taken for laparoscopic pyeloplasty.

s33. COMPARISON OF LAPAROSCOPIC AND OPEN NEPHRECTOMIES IN CHILDREN

Pavel Zerhau,M.D.,Ph.D., Jiri Tuma,M.D.,Ph.D.,
Department of Pediatric Urology, University Childrens Hospital Brno, Cernopolni 9, 662 63 Brno, Czech Republic

INTRODUCTION: We compare our experience with laparoscopic and open nephrectomy in a pediatric population.

METHODS AND PROCEDURES: Between August 1997 and October 2001 18 children aged 13 months to 15 years underwent laparoscopic nephrectomy on account of benign kidney disease, 11 by a transperitoneal , 7 by the retroperitoneal approach. Retrospectively this group was compared with a group of 18 children aged 1 month to 15 years in which in 1995-1998 open nephrectomy was performed for the same reasons .

RESULTS: Mean operative time was 101,6 versus 54,2 minutes (p=0,00003), the postoperative drainage of the wound was 1,05 days versus 2,0 days (p=0,009), the mean hospital stay was 4,9 versus 6,6 days (p=0,0003), analgetics were administered for 21,3 and 31,25 hours after operation (p=0,03) in the laparoscopic and open nephrectomy groups, respectively. As to beginning of oral food intake there was no significant difference, a blood transfusion was administered to one patient after the open operation. One patient developed a postoperative complication after open nephrectomy.

CONCLUSION: Operative time was significantly longer in our laparoscopic group, postoperative hospital stay, postoperative drainage and analgetics administration were significantly shorter than for open surgery. We consider laparoscopic nephrectomy in children a safe and useful method.

s34. LAPAROSCOPIC ANDERSON-HYNES PYELOPLASTY IN CHILDREN

Bahr M, Korn St, Schier F,
Department of Pediatric Surgery, University Medical Center Jena, Bachstr. 18, 07740 Jena, Germany

Objective: The experience of transperitoneal laparoscopic dismembered pyeloplasty in 12 children is presented.

Methods and procedures: In 12 children (aged 4 months to 14 years, median 4 years) a laparoscopic Anderson-Hynes pyeloplasty was performed. The patient was in a lateral decubitus position. A 5-mm laparoscope and two 2-mm trocars were inserted. The access to the pelvis was transperitoneal. In the last three patients, double-J stents were used.

Results: The operative times were 6.5 hours in the first patient and 2.5 hours in the second patient. None of the following procedures exceeded 3 hours operating time. A urinoma, which was treated using a percutaneous pyelostoma, developed postoperatively in the 14-year-old boy. No other complicatins occurred. Ultrasonographic controls at 3 months postoperatively showed a residual dilatation of the pelvis in all children. Scintigraphic controls were performed one year after surgery. The results were comparable to the "open" approach.

Conclusion: The excessive operating time in the first patient was due to inexperience with the approach. Technical improvements resulted a significant reduction in operating time in the second patient. Even with practice, the operating time still remained longer than in conventional surgery. The first patient would have benefited from the placement of a stent. The procedure has the usual advantages of laparoscopic techniques, but is technically demanding because of extended laparoscopic suturing. The question whether the transperitoneal or the retroperitoneal approach is better will only be answered by comparing larger series of both approaches. We prefer the transperitoneal approach because a natural cavity is used and because the approach is familiar to most laparoscopists. The opened peritoneum will seal off within a day.

s35. DEXTRANOMER ENDOSCOPIC INJECTION FOR URINARY INCONTINENCE

Paolo Caione, Nicola Capozza
Div. of Pediatric Urology, Dept. of Surgery. Bambino Gesù Children's Hospital, IRCCS - Rome - Italy

INTRODUCTION: Different bulking substances have been proposed to gain continence with endoscopic treatment. Deflux tm is a new synthetic material.

METHODS: Over a 2-year period, 16 patients aged 8 to 22 years (mean 13.5 years) were treated endoscopically for stress urinary incontinence using Deflux (3 neurogenic bladder, 13 structural sphyncteric deficiency). Deflux is a suspension of dextranomer in a 1% hyaluronan solution. Injected volume ranged from 1.8 cc to 4.0 cc (average 2.5 cc). Six patients had 2 injections and 3 had 3 injections. Results at 6 and 12 months follow-up were compared with the preoperative status (Fisher's Exact test).

RESULTS: 37 injections were performed (mean 2.3 injections/patient). Dry interval increased from 35 mins to 80 mins average (0-190 mins, p < 0.005). Functional bladder capacity changed from 85 cc to 125 cc (p < 0.005). Three patients (18.7%) became fully day-time dry (2 -3 hours voiding or CIC interval). 2 patients became night-time dry, 6 (37.5%) ameliorated the nocturnal pad-test. In 8 patients (50.0%), results were not changed. No side effects or upper tract deterioration were observed.

CONCLUSION: Endoscopic injection of Deflux improved urinary continence in selected patients. The substance was demonstrated to be safe and easy to inject, increasing outlet resistance.

s36. LAPAROSCOPIC VERSUS OPEN NEPHRECTOMY IN PEDIATRIC POPULATION

Luis García-Aparicio M.D.; Josep M. Ribó M.D.; Victoria Juliá M.D.,Ph.D.; Jordi Rovira M.D., Ph.D.; Xavier Tarrado M.D.;
Luis Morales M.D, Ph.D.
Deparmet of Pediatric Surgery Unitat Integrada Hospital Sant Joan de Déu-Hospital Clínic University of Barcelona.

Purpose: Laparoscopy has become a successful approach for many procedures in pediatric urology. We compare the laparoscopic and open approach to perform nephrectomies in pediatric population.

Material and Methods: A total of 53 patients who underwent nephrectomy for renal benign disease from 1994 to 2000 in our institution were reviewed retrospectively for relevant clinical data. Laparoscopic nephrectomy (LN) were performed in 25 patients and open nephrectomy (ON) in 28. The transperitoneal approach was performed in the laparoscopic group.

Results: Mean operative time was 135,4 versus 120,5 minutes in the laparoscopic and open groups, respectively. There were no conversions to open surgery. Blood loss was insignificant in both groups and there were no intraoperative complications. Mean time for oral intake after surgery was 7.2 and 12.7 hours for laparoscopic and open nephrectomy. Mean hospital stay was better in the laparoscopic approach than in the open nephrectomy, 2.6 and 5.1 days, respectively.

Conclusions: Laparoscopic nephrectomy and nephroureterectomy is the technique of choice for renal benign disease in pediatric population. Although operative time is longer, discomfort and the hospital stay is shorter than open procedure.

s37. TRANSVESICOSCOPIC CROSS-TRIGONAL URETERIC REIMPLANTATION UNDER CARBON DIOXIDE PNEUMOVESICUM FOR VESICOURETERIC REFLUX: A NOVEL TECHNIQUE

Yeung CK1, Borzi PA2.
Division of Paediatric Surgery, Department of Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong1, and Royal and Mater Children's Hospitals, Brisbane, Australia2.

Traditionally bladder surgery is performed either through a cystoscope or an open vesicotomy. With the advent of minimally invasive surgery in children, laparoscopic ureteric reimplantation through a transperitoneal extravesical approach has been described. The approach however necessitates transgression of the peritoneal cavity and can be technically difficult in the small pelvis of a young child. From a pilot animal model we have found that with carbon dioxide insufflation the bladder could provide a large potential space allowing various intravesical endoscopic procedures to be conducted. Objective: To evaluate the effectiveness of endoscopic intravesical cross-trigonal ureteric reimplantation under carbon dioxide insufflation of the bladder, or pneumovesicum, in infants and children.

Patients and Methods: Twelve patients (7 boys, 5 girls) with dilating primary vesicoureteric reflux (6 bilateral; 18 refluxing ureters), associated with recurrent urinary tract infections and multiple pyelonephritic renal scarring, underwent endoscopic Cohen's transtrigonal ureteric reimplantation with carbon dioxide pneumovesicum. Age ranged from 10 months to 13 years (mean: 4.3 years). The bladder was first drained and then insufflated with carbon dioxide to 10-12 mm Hg pressure, with a balloon catheter inserted per urethra to occlude the internal urethral meatus. A 5 mm Step port was inserted over the bladder dome and a 5 mm 30 degree scope was used to provide intravesical vision. Two more 3 mm working ports were then inserted on either side of the camera port. Intravesical mobilization of the ureters, dissection of submucosal tunnel and a Cohen's type of ureteric reimplantation using interrupted 5 zero poliglecaprone or polydioxanone sutures was then performed under endoscopic guidance. Bladder drainage by an urethral catheter was maintained for 24-48 hours post-operatively.

Results: Endoscopic transtrigonal ureteric reimplantation with carbon dioxide pneumovesicum was successfully performed in all twelve patients. The mean operating time was 108 minutes (range: 75 -145 minutes). One boy developed mild scrotal emphysema post-operatively that subsided spontaneously. The camera port was displaced after a successful reimplant in another patient leading to open conversion. All patients recovered uneventfully and remained well.

Conclusions: This preliminary experience illustrates that endoscopic intravesical ureteric mobilization and transtrigonal ureteric reimplantation can be safely and effectively performed with carbon dioxide insufflation of the bladder. The long-term outcome and potential physiological effects of carbon dioxide pneumovesicum on the bladder and upper tract function will need to be further evaluated.

s38. THORACOSCOPIC UPPER THORACIC SYMPATHECTOMY FOR PRIMARY PALMAR HYPERHIDROSIS IN CHILDREN AND ADOLESCENCE A 10 YEARS EXPERIENCE

Vadim Kapuller, M.D., Zahavi Cohen, M.D.,
Dept. of Pediatric Surgery, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel.

We report our experience over the last 10 years with thoracoscopic sympathectomy for severe palmar hyperhidrosis in children and adolescents. 278 patients underwent 553 thoracoscopies. There were 170 females and 108 males, age ranging between 5.5 and 18 years.

An operative one-channel thoracoscope was used through a single 10 mm axillary port in all patients. The procedure include ablation of T2 and T3 ganglions, each side.

272 patients (98%) had immediate and permanent relief of palmar sweating. The immediate postoperative course was uneventful in 265 patients. Ten patients had a residual pneumothorax following surgery, that required a 24-hour intercostal drainage and three patients had bleeding from intercostal vessels that were successfully managed.

The obvious advantage of the thoracoscopic approach to sympathectomy is the feasibility of performing bilateral procedure at the same time as well as minimal operative trauma, easy postoperative course, short hospitalization, excellent cosmetic results and a quick return to school and normal activities.

We emphasize the benefit of early surgery in children with severe palmar hyperhidrosis, thus avoiding many years of psychological, social and physical discomfort.

s39. LAPAROSCOPY AND CARBON DIOXIDE VERSUS AIR REDUCE PERITONEAL, SYSTEMIC, AND PULMONARY IMMUNE RESPONSES

BM Ure, MD, NMA Bax, MD, TA Niewold, PHD, GJ Van Essen, MD, DC Van Der Zee, MD
Department Of Pediatric Surgery, University Medical Center Utrecht And Institute For Animal Science And Health, Lelystad, The Netherlands. Department Of Pediatric Surgery, Hannover Medical School, Hannover, Germany.

The immunological impact of laparoscopy versus laparotomy with exposure to CO2 and room air was investigated.

Method: Twenty piglets were randomized for: CO2 laparoscopy, air laparoscopy, CO2 laparotomy, air laparotomy. Laparotomy was performed in a sterile balloon with a pressure similar to laparoscopy. Interleukine-1, interleukine-6 (IL-6), tumor necrosis factor (TNF), polymorphnuclear cells (PMN) and macrophages (mf) were determined in abdominal lavage fluids at 0, 2, and 48h, and in alveolar fluids at 48h. Macrophages were assessed for reactive oxygen species production (ROS). Systemic responses included white blood cell count (WBC) and cytokines.

Results: Peritoneal: Laparotomy versus laparoscopy, when performed with CO2, significantly increased PMN and decreased the %mf. There was a significant increase in IL-6, and a four-fold increase in mf ROS. Similar differences between the procedures were found with exposure to air. The use of air versus CO2 in laparoscopy, but not in laparotomy, resulted in an increase of peritoneal PMN, and a decrease of the %mf up to 48h. Air increased the local IL-6 release in both procedures, and fourfolded mf ROS. Systemic: Laparotomy produced a significant increase in WBC, which was more pronounced with exposure to air. No alteration of other cytokines was seen. Pulmonary: The number of mf and the mf ROS were significantly increased after air versus CO2 laparoscopy, but not in the laparotomy groups.

Conclusions: Laparoscopy and exposure to CO2 reduced immune responses. Peritoneal responses were affected to a larger degree than systemic and distant organ parameters. Laparotomy overruled the effects of CO2 on chemotaxis and distant organ injury, but not on peritoneal cytokine release.

s40. PAIN MANAGEMENT AFTER MINIMALLY PECTUS EXCAVATUM REPAIR

Anton Gutmann,MD Maria Vittinghoff,MD Roswitha Gössler,MD Andrea Stockenhuber,MD Christiana Justin,MD Jürgen Schleef,MD Michael Höllwarth,MD.
Department of Anaesthesiology and Intensive Care Medicine,University of Graz, Austria, Department of Paediatric Surgery, University of Graz, Austria

Objective: We assessed the effectiveness of three different methods of pain relief in children undergoing minimally invasive repair of pectus excavatum.

Patients and methods: a retrospective review of the pain protocols of 41 patients ( 8 f, 33 m) aged 8 - 25 years ( mean 12,9) operated on between January 2000 and October 2001 was conducted. 19 patients received bilateral paravertebral infusions of local anaesthetics; 17 received lumbar epidural infusions of local anaesthetics together with morphine; and 9 received thoracal epidural infusions of local anaesthetics.

All patients were regularly assessed for pain ( 0 = no pain, 10 = worst pain) as provided in our pain protocol. Whenever the pain score was higher than 4, an additional intravenous opioid bolus was administered. The charts of patients were also reviewed for adverse events.

Results: All methods showed good results with low pain scores and we saw no major adverse events. Details are shown in Table 1.

	Paravertebral	Lumbar epidural	Thoracal epidural
Mean pain score	1,1	0,9	2,9
Mean opioid bolus needed per patient	2,6 (0-16)	1,2(0-10)	6(4-9)
Catheter dislocation	2	2	1
Vomiting	2	5	0
Urine retention	0	6	2
Horner Syndrome	1	0	1
Itching	0	1	0

Conclusions: Paravertebral infusion of local anaesthetics was best. Lumbar infusion of local anaesthetics together with morphine showed better pain control than thoracal infusion of local anaesthetics. The higher incidence of vomiting and urine retention in the lumbar epidural group needs additional therapy.

s41. SPLENECTOMY FOR PEDIATRIC HEMATOLOGIC DISEASE

Perry Stafford MD , Eileen Houseknecht RN, Daniel von Allmen MD, Michael Nance MD, and Kim Smith-Whitley MD
Children's Hospital of Philadelphia, Philadelphia, PA.

INTRODUCTION: Splenectomy has an established role in the treatment of selected hematologic diseases in children. The purpose of this outcome study was to compare open with laparoscopic splenectomy.

METHODS: A retrospective chart review identified 154 children who consecutively underwent elective splenectomy for hematologic disease during the twelve year period (1988-2001) at a single teaching hospital. Demographic information and outcome parameters were identified and compared between the open splenectomy (OS,n=99) and laparoscopic splenectomy (LS, n=55) groups. The unpaired Student's test was used for statistical comparison with a P value of less than 0.05 considered significant.

RESULTS: The two groups were demographically similar. Operative time was longer and times to diet and discharge were shorter in LS than OS (P<0.05). There were no significant differences in other collected outcome parameters. Operative time for LS decreased with increasing experience. Family and patient satisfaction were good for both OS and LS. There were three deaths, all due to patient disease.

CONCLUSION: OS and LS are equally safe and efficacious surgical procedures. Standard in-hospital outcome parameters revealed no significant differences between the two techniques except a shorter time to diet and discharge in LS. Selection of the surgical technique for elective splenectomy in children with hematologic disease should be made by the surgeon based on experience and patient preference.

s42. LAPAROSCOPIC MANAGEMENT OF IMPALPABLE TESTES : A MULTI-INSTITUTIONAL STUDY OF THE ITALIAN SOCIETY OF VIDEO SURGERY IN INFANCY

A.Papparella M.D., P.Parmeggiani M.D. 1, G.Cobellis M.D. , L.Mastroianni M.D. 2, G.Stranieri M.D. 3, N.Pappalepore M.D.4 ,G.Mattioli M.D. 5, C. Esposito M.D. 6 and M.Lima M.D.7.,
From the Division of Pediatric surgery , II University of Naples, Naples 1. Salesi Hospital , Ancona 2. Pugliese Hospital ,Catanzaro 3 .Spirito Santo Hospital, Pescara 4 . G. Gaslini Hospital Genova 5.University of "Magna Graecia", Catanzaro 6, University of Bologna 7 .

We report the results of a study of the Italian Society of Video Surgery in infancy on the laparoscopic management of impalpable testis.

From 1992 till 1998 , 344 boys from 2 to 10 years old ( median age 4.4) underwent laparoscopy for a total of 378 impalpable testes . Five laparoscopic findings were considered : blind ending cord structures , intrabdominal testis, cord structures entering the inguinal ring, testicular ectopia and agenesy. A primary orchidopexy , staged Fowler-sthephens or autotrasplant procedure were performed , depending on patency and the distance from the internal inguinal ring . An inguinal exploration was performed for cord structures into the ring .In 131 (38%) cases for a total of 145 testes an intrabdominal testis were found . 90(62.06%) testicular units were found nearby the ring and a primary orchidopexy was performed. 55 ( 37,9%) Testicular units were found high in the iliac fossa or the pelvis. In 42 cases a Fowler Sthephens and/or a testicular autotrasplant were performed. In 149 patients cord structures into the inguinal ring were observed and 139 underwent an inguinal exploration . Blind ending cord structures were found in 78 patients and in 6 cases testicular agenesy. No complications were recorded. The laparoscopic classification of abdominal testis is reliable and can disclose the most suitable surgical technique .Laparoscopy is a valuable tool in the diagnosis and treatment in the 62.5 % of the patients.

s43. ENDOSCOPIC SURGERY OF DIAPHRAGMATIC ANOMALIES : A MULTICENTRIC STUDY OF THE GROUPE D'ETUDE EN COELIOCHIRURGIE INFANTILE (GECI). PART 2 : MORGAGNI'S HERNIAS

F. Becmeur,MD , P. Philippe,MD, D. Vanderzee,MD, N. Bax,MD, H. Allal,MD, O. Reinberg,MD, M. Lima,MD, Y.Heloury,MD, F. Berchi,MD, A.Debacker,MD, M. Robert,MD, C. Salakos,MD, J.L. Alain,MD, F. Schier,MD, J. Schleef,MD., R. Moog,MD.,
CHUHautepierre, Strasbourg;CHL,Luxembourg;WKZ,Utrecht; CHU,Montpellier;CHV, Lausanne; CHU,Bologna; CHU,Nantes; HUMI12Octubre, Madrid; AZVUB, Brussel; CHU,Tours; CHR,Roubaix; CHU,Limoges; CHU,Iena; KH,Graz

Objective of the study: The aim of this study was to establish laparoscopy as the procedure of choice for the repair of Morgagni's hernia in children.

Methods and procedure: A retrospective questionnaire study was conducted in January 2001 among the members of the GECI.

Results: We collected 22 cases, with 23 operations (mean age: 37 mo., mean weight: 13.9kg, 1 redo). There were 5 pts with Down syndrome and 1 with myopathy. Only 3 trocars were used in 17/23 cases. Colon(15), liver(8), stomach(5), bowel(4) or omentum (1) were found in the hernia. A sac was removed in 12 of 18 cases where it was present. The defect was closed in 18/23 patients by different techniques of direct suture and with a prosthetic mesh in 4. One conversion was neccessary because of the large size of the defect in a small child. One bowel injury was repaired at laparoscopy.One pneumothorax was drained postoperatively. Mean operative time was 94 minutes. Mean hospital stay was 4,7 days. With a mean follow-up of 13 months, there was only 1 recurrence, reoperated successfully by laparoscopy.

Conclusion: Laparoscopic repair of Morgagni hernia, by direct closure or with a patch, is easy, safe, and effective in children. From our data, we suggest that laparoscopy should become the standard for repair of this type of diaphragmatic hernia in children.

s44. THORACOSCOPIC EXCISION OF AN INTRAMURAL OESOPHAGEAL DUPLICATION CYST

Adam Watts, M.D., Fraser D Munro, M.D., Gordon A MacKinlay, M.D.
The Royal Hospital for Sick Children, Edinburgh, Scotland

Objective: To report a case of an intramural oesophageal duplication cyst in a 7 month old boy which was totally excised thoracoscopically and to show the operative technique.

Method: Review of case record

Report: A 7 month old male presented with a chronic cough. CXR showed hyperinflation of the right lower and middle lobes. A cyst was seen in the posterior part of the right hilum on MRI scan.

Surgery was carried out with one lung ventilation after left endobronchial intubation. Three ports were used ( Two 5mm and one 3.5mm). The cyst was seen to be arising from the oesophagus with the muscle thinned over its surface. Dissection was made on the surface of the cyst and the muscle incised a little away from the oesophagus. The cyst was able to be dissected away from the oesophageal mucosa in its entirety. The muscle layer was then repaired with vicryl. The operating time was 100 mins. The patient made an uneventful recovery and is swallowing normally.

Conclusion: Complete excision of an intramural oesophageal duplication cyst can be accomplished thoracoscopically. Previous authors have suggested leaving the portion of the cyst most closely applied to the oesophagus in situ, in order to avoid the dissection between cyst and oesophageal mucosa, and ablating the lining with diathermy or laser. This has, however, been associated with a significant recurrence rate and complete excision, if possible, seems preferable.

s45. LAPAROSCOPIC SIGMOID VAGINAL REPLACEMENT

Bailez M , Di Benedetto V, Elmo G and Korman L.
Pediatric Surgery . Htal J. P. Garrahan Bs As . Argentina

Sigmoid vaginoplasty is an alternative technique for vaginal replacement in patients with flat perineum and little inter-uretero-rectal space (male pseudohermaphroditism), in those patients presenting with associated malformations requiring simultaneous reconstruction (cloaca, recto-vestibular or recto-vulvar fistula and in those with solitary vaginal agenesis after failure of other treatment modalities). Major disadvantages of this technique are that a laparotomy is always necessary which is associated to known complications such as pain, nasogastric suction. After the advent of mechanical suture, we have abandoned the use of routine nasogastric suction and our next goal was to avoid laparotomy. In April 2000 (IPEG meeting) we reported the first patient who underwent laparoscopic sigmoid vaginal replacement. We now present an update on our experience with this procedure in 8 patients. Their mean age was 16.3 y. Six patients had a Mayer Rokitansky Syndrome and 2 a complete androgenic resistance previously treated by laparoscopic bilateral orchydectomy. All patients were informed about different treatments and chose this procedure. We have used 4 ports : A 10mm one (umbilical ) , a 12 mm( right lower quadrant) and two 5 mm.(left lower quadrant and hypogastric) .The lens was initially introduced through the umbilical port and afterwards inserted through the right lower quadrant one in order to achieve a better visualization of the vascularization of the sigmoid. The sigmoid was trans-iluminated with a 5 mm lens through the port located in the left lower quadrant. After isolating a segment of the sigmoid using endoclips, bipolar or ultrasonic devices and two endostapplers , we undertook a perineal dissection creating a space between the urethra and the rectum under laparoscopic vision.Colo-colonic anastomosis was achieved using a circular mechanical suture through the rectum and taking outwards the proximal end of the colon through the umbillicus. The remaining end was placed at the endosuture. Both the ensamble and shooting were done under laparoscopic control. The peritoneum near the Douglas space was incised in order to allow the passage of a forceps from the perineum which enabled the descent of the isolated bowel. Vaginoplasty was completed through the perineal route. Mean operative time was 4 hours . There were no intra or post-operatory complicationsexcept for an accidental opening of the bladder that was sutured. All patients were able to tolerate food after 24 hours of the procedure and 7 were discharged after 48 hours of the operation We learned that a complete perineal dissection of the vesicorectal space is required before trying to open it from above A rigth pelvic kidney made the procedure more difficult , requiring more "camara work" .On the other hand ,a left pelvic kidney exposed the sigmoid vessels, making isolation of the colon easier.. Viability and patency of neovagina are excellent after a mean follow up of 6 months (4- 20 m )

IPEG 2002 ORAL ABSTRACTS

s01.ROBOTIC ENTEROTOMY REPAIR IN FETAL PIGS

Celeste M. Hollands, MD,Laramie N. Dixey, RN, Department of Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA, Department of Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana

s02. THORACOSCOPIC REPAIR OF ESOPHAGEAL ATRESIA WITH FISTULA - OUR INITIAL EXPERIENCE

Marcelo Martinez Ferro MD, Gaston Elmo MD, Horacio Bignon MD National Children's Hospital J.P.Garrahan. University of Buenos Aires. Buenos Aires, Argentina.

s03. INTRATRACHEAL PULMONARY VENTILATION INCREASES THE SAFETY OF PEDIATRIC LAPAROSCOPY IN THE SETTING OF RESPIRATORY FAILURE

s04. VIDEOASSISTED REMOVAL OF TWISTED NEONATAL OVARIAN CYST

A. Porreca M.D. , A.Tramontano M.D. Ospedale Santobono, Divisione di Chirurgia d'Urgenza, Naples, ITALY

s05. MINIMAL INVASIVE OESOPHAGECTOMY AFTER CORROSIVE BURN IN CHILDREN: A CASE REPORT

Gesmundo R. ,Garrone C. ,Lonati L., Morino M., Canavese F. Divisione di Chirurgia B Ospedale infantile Regina Margherita - Torino - Italy Divisione di Chirurgia D'Urgenza Ospedale Giovanni Battista - Torino - Italy