IPEG 2002 POSTER ABSTRACTS

p01. LAPAROSCOPIC STAGING FOR HODGKIN´S DISEASE IN CHILDREN

Edward Esteves, MD; Elecy M. Oliveira, MD; Patricia O. Brito, MD; Cesar Bariani, MD; Rosemary G. Crocetti, MD.
Pediatric Oncology Division, Araujo Jorge Hospital for Cancer, Goiania (GO), Brazil

There are some controversies regarding surgical staging for Hodgkin´s disease (HD) in children, due to the good results of chemotherapy (CHT) and radiotherapy allied to advances in imagenology. Considering the risk of under or superstaging without surgical exploration, specially in clinical stages higher than 2A or in those who need splenectomy or oophoropexy, the advantages of laparoscopy compared to laparotomies allow more adequate staging with low morbidity. Methods: The authors analysed prospectively all childrens (n=21, ages 4-18 years) submitted to laparoscopic staging for HD, with or without concomitant thoracoscopy. Laparoscopic procedures were accomplished with 3-5 trocars, including multiple biopsies (lymphnodes, liver, spleen, masses), splenectomies (11), oophoropexy (9), appendectomy (6), coupled with bone marrow biopsies. Results: Change of clinical preoperative staging ocurred in 19% of the children after surgery. Four children also required thoracoscopy. All procedures were achieved without complications, approaching all abdominal quadrants with few trocars. CHT could be started earlier than commonly accomplished after laparotomies (mean 3 days versus 7 days, p<0,05). Conclusions: Patients with HD in whom abdominal or thoracic exploration is necessary, can be benefited by laparoscopic staging with or without splenectomy, with less complications related to surgical trauma, allowing early postoperative adjuvant therapy according to a correctly staged disease.


p02. LAPAROSCOPIC ADRENALECTOMY FOR NEUROBLASTOMA: A REPORT OF 2 CASES

Zvonimir Milas, M.D. and Mark Wulkan, M.D.,
Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston

Objective: The aim of this study is to describe the treatment and outcome of 2 children who underwent laparoscopic adrenalectomy (LA) for neuroblastoma.

Methods and Technique: Case I: A 12-month-old girl was diagnosed with a 3.2 x 4 cm right adrenal mass during work-up for thelarche. Case II: A 31 month-old boy was diagnosed with a 4x5 cm left adreanal mass during work-up for persistent fevers and hip pain. Metastatic neuroblastoma was confirmed by iliac crest biopsy. Neoadjuvant therapy was administered for 3 months. Both children underwent successful LA with removal of their tumors and surrounding lymph nodes. The specimens were placed in a laparoscopic specimen retrieval bag and morselated in situ. The tissue samples were adequate for all required pathologic analysis, including genetic studies and nMYC. Mean operative time was 185 min. There were no intra- or peri-operative complications. Both children were discharged home within 24 hours. One year post-operatively, the 12 month-old girl is disease free without further therapy. Four months post-operatively, the 31 month-old boy has healed well from surgery. His metastatic tumor is being treated with further chemotherapy and bone marrow transplantation.

Conclusions: Our preliminary data suggests that LA for neuroblastoma can be safely performed in children. The benefits of LA, including minimal surgical morbidity and a significantly shorter hospital stay, are to be expected in this patient population.


p03. LAPAROSCOPIC RESECTION OF PARARENAL TUMOURS

C.F. Schwindak,M.D., F.D. Munro,M.D., G.A. MacKinlay,M.D.
The Royal Hospital for Sick Children, Edinburgh, Scotland

Objective: Recent reports on early experience with laparoscopic pararenal surgery in children have been made and we present our experience dealing with three patients with a diagnosis of pararenal tumours.

Method: An 11 year old boy had a right adrenal pheochromocytoma excised at laparotomy 2 years earlier. He then presented with a left varicocele with no symptoms or signs of adrenergic hyperactivity. Abdominal ultrasound revealed a 5 cm mass in the left anterior renal hilum compressing the renal vein. Preoperative antihypertensive medication was not required.

A 9 year old boy presented with a 5 week history of headaches, fever, nausea, lassitude and weight loss. On ultrasound a 6,5 x 4,7 x 6 cm mass was seen in the region of the left adrenal. Phenoxybenzamine alpha blockade and propranolol were instituted for 1 month pre-operatively

A 6 year old girl presented with a 4 month history of breast and pubic hair development and accelerated growth. MRI scan of the abdomen showed a mass related to the left adrenal gland.

Results: Laparoscopic resection was successfully performed in all 3 patients. The patients with phaeochromocytoma were remarkably stable under GA with no need for cardiovascular intervention. Pathology confirmed complete excision in all 3 cases. All patients remain well on follow up.

Conclusions: The laproscopic approach to pararenal tumours is safe and provides better visualisation and dissection than open techniques.


p04. TWO-PORT VERSUS 3-PORT LAPAROSCOPIC APPENDECTOMY IN CHILDREN WITH UNCOMPLICATED APPENDICITIS

Dr. Abdulrahman Al-Bassam, MD, Dr. Abdul Rauf Khan, MD
Division of Paediatric Surgery, Department of Surgery, College of Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia, P.O. Box 86572, Riyadh 11632 Saudi Arabia

Objective: Laparoscopic appendectomy (LA) is commonly performed through 3-port technique. We compared our experience of 2-port laparoscopic assisted appendectomy (LAA) to 3-port LA with uncomplicated appendicitis (UA) in term of the efficacy, safety and cost.

Methods:We evaluated all 86 children aged 3 to 12 years with UA undergoing LA (2-port n=45, 3-port n=41) during 4.5 years period. Technique depends upon the surgeon's choice and position of appendix. We excluded all children (2-port n=8, 3-port n=15) with complicated appendicitis (CA).

Results: There was no difference in age at the time of presentation, gender, weight, duration of symptoms and severity of disease in both techniques of LA. In 2-port LAA, the operative (40 versus 68 minutes, P<0.05) and anesthesia (67 vs. 96 minutes, P<0.05) time were shorter. Average post-operative stay (2.5 days in 2-port vs. 3.3 days in 3-port) and analgesia requirement were also less in 2-port LAA. Two children (3-port LA) required conversion to open appendectomy. There was no post-operative complication in either group. Extra cost of endo-loops with one port and one day hospital stay was saved with 2-port LAA.

Conclusion: We concluded that 2-port LAA is a safe and effective alternative for the management of UA. When successful, overall cost is less in 2-port LA because of advantage of quicker to perform, less anesthesia time, no requirement of endo-loops, endo-clips, or endo-GIA, shorter hospital stay and less post-operative analgesia.


p05. WHY PEDIATRIC SURGEONS CAN`T AFFORD NOT TO PERFORM LAPAROSCOPIC APPENDECTOMY

Mariana Bachmann de Santos M.D. ,
HOSPITAL PRIVADO DE COMUNIDAD, MAR DEL PLATA

I. Laparoscopic pediatric appendectomy (LPA) has been rejected because of apparent small benefit. The importance in trainig pediatric surgeons so that endosurgical procedures (EP) can be performed safely is not to be neglected. We looked at our LPA in relation to all EP performed in a first 4 year period.

II. 151 EP were performed since august 1997 in patients from 4500g on, aged 3 month to 16 years. 110 were LPA the others corresponding to 9 gynecologic, 9 urologic, 7 thoracoscopic interventions and 8 cholecystectomies, 1 fundoplicartion, 1 anterior diaphragmatic hernia and 6 miscellaneous.

III. Operating time decreased from average 68 minutes (first 10) to 40 minutes (actual) for LPA. 7 intraabdominal abscesses, 6 treated with oral antibiotics alone and 3 conversions in the first 66 patients were recorded. In the no LPA EP 1 nefrectomy was converted and 1 trocar site omentum hernia closed. No bleeding, no wound or abdominal wall infection and no procedure related injury occured.

IV. LPA might bring small benefit for patients but is extremely usefull to keep pediatric surgeons trained for performing a great variety of EP.


p06. OMENTAL INFARCTION IN CHILDREN: A TWISTED 'TAIL' OF A NOT SO INFREQUENT PROBLEM

Jorge R. Beltrán, MD , Guy F. Brisseau, MD, Marc A. Levitt, MD, Scott C. Boulanger, 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, SUNY @ Buffalo, Buffalo, NY, USA

Purpose: Miniature access surgery (MAS) for appendicitis affords a better abdominal cavity inspection and diagnosis of other surgical maladies that may otherwise have been missed with a limited RLQ incision. Omental infarction is a rare cause of acute abdominal pain with an incidence of 0.1%. We hypothesized that with MAS, omental infarction would be more commonly diagnosed.

Methods: We reviewed all patients operated on with a diagnosis of appendicitis during one year.

Results: 203 patients were compiled; 195 (96%) were managed with MAS. 38 cases (18.7%), had a normal appendix and 5 of these had infarcted omentum, (13.5%). The incidence of omental infarction was 2.5%. These children were 7 and 11 years of age, and all were obese (BMI >97th %). The pain was prolonged (1-3 days) and did not change location. Localized peritonitis was not always at McBurney's point. No patients had nausea or vomiting, all were afebrile, and had a mild leukocytosis (mean, 13000).

At MAS, all 5 patients had a normal appendix with a distal segment of infarcted omentum in the RLQ. The omentum were resected with MAS and all were discharged in <48 hours. Pathologies were consistent with acute ischemia and chronic fibrosis.

Conclusion: Omental infarction illustrates the utility of MAS in children with a diagnosis of appendicitis. Our data suggests an increased incidence of omental infarction likely due to the increased diagnostic yield of MAS. Further, the infarcted omentum can be easily managed with MAS.


p07. SURGICAL PROCEDURE FOR VIDEO-ASSISTED COLONIC PULL-THROUGH WITH SECTION OF INFERIOR MESENTERIC ARTERY

D. Falchetti MD, F. Torri MD, S. Benvenuti MD, L. Tonegatti MD, S. Milianti MD, B. Morelli MD, F. Braga MD, G. Ekema MD  

Introduction We perform video-assisted endorectal pull-through for the treatment of Hirschsprung's disease with a modified Georgeson's procedure. We reviewed our experience to assess its safety and advantages

Methods The left colon is freed just dividing the inferior mesenteric vessels (IMV) at their origin next to the aorta. This procedure allows section of the mesocolon on its avascular plane from the splenic flexure to the pelvic peritoneal reflection and preservation of its larger vessels (left colic and sigmoid arteries) blood supply. This dissection is safely away from nerves around Waldeyer's and Denonvillier's Fascia. As usual the pelvic rectum is dissected by endorectal mucosectomy from below, starting about 0.5cm above the pectinate line, and after the section of the prolapsed muscular cuff the colon completely mobilized is loosely pulled down transanally until the level of normal bowel innervation. The colo-anal anastomosis is always performed by hand.

Results This technique has been used in 15 patients ageing 25 days to 12 years. In every case adequate mobilization was achieved. No intraoperative problem required conversion to open surgery.

Conclusion Video-assisted endorectal pull-through with IMV section is a safe technique and allows quick and neat mobilization of the left colon.


p08. LAPAROSCOPIC RECTOPEXY: A NEW APPROACH IN CHILDREN

Munther J Haddad, Ravindra H Ramadwar, Simon Clarke
Department of Paediatric Surgery, Chelsea & Westminster Hospital, London, UK

Aim: Rectopexy is one of the accepted forms of treating full thickness rectal prolapse in children. A variety of techniques including laparoscopic rectopexy have been reported in adults. We report our experience of laparoscopic rectopexy in children.

Method: Patients with full thickness rectal prolapse resistant to conservative treatment underwent laparoscopic rectopexy. Three 5mm ports were inserted, one in right upper quadrant for a zero degree telescope, one in left upper quadrant and one in right iliac fossa. Two graspers were introduced through the lateral ports and the rectum was identified. The mobility of the rectum was checked. The peritoneum was incised lateral to the left internal inguinal ring to create a raw area. The rectum is fully stretched and sutured to the transversus abdominis muscle with 2-0 ethibond sutures. Postoperatively feeding was commenced once the patients were awake. The patients were discharged the next day and were followed up in the clinic after six weeks.

Results: All 4 patients underwent this technique. The median operation time was 50 minutes and the median hospital stay was 24 hours. All patients tolerated the procedure well and there were no complications. At follow-up there were no recurrences.

Conclusion: Laparoscopic rectopexy can be easily performed in children. Our technique is simple and had excellent results. We recommend laparoscopic rectopexy in children with rectal prolapse resistant to conservative management.


p09. LAPAROSCOPY ASSISTED ANORECTAL PULL-THROUGH FOR RECTOCLOACAL FISTULA: A CASE REPORT

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 successful laparoscopy assisted anorectal pull-through and posterior skin-flap vaginoplasty.

Case report: A 13-month-old female child had initial sigmoidostomy at birth, presented with rectocloacal anomaly: double vagina and intermediate confluence of urogenital sinus with a high type of rectovaginal fistula. She underwent laparoscopy assisted anorectal pull-through and posterior skin-flap vaginoplasty, simultaneously. Following vaginoplasty, the distal rectum was laparoscopically dissected and the rectovaginal fistula divided. Laparoscopic muscle stimulator with 5mm diameter showed good contraction of levator muscles in the pelvic floor. Dilatation of the pull-through tract was achieved by inserting a guide-wire and balloon catheter into the center of the levator muscle sling and muscle complex, with laparoscopic visualization. Rectal pull-through and anastomosis between rectum and anus were successfully completed. The operation took 4.25 hours, and blood loss was minimal.

Conclusions: Laparoscopy and laparoscopic muscle stimulator provide excellent visualization of the rectovaginal fistula and levator muscle sling. Better visualization of the tract facilitates successful rectal pull-through.


p10. LAPAROSCOPIC MECKEL´S DIVERTICULECTOMY

Libor Janecek,M.D.
Department of Pediatric Surgery University Hospital,Hradec Králové,Czech Republic

Meckel´s diverticulum has an incidence of approximately l-2 percent in the population, may be present at any age and carry an approximately 4 percent risk of complications throughoutlife. Over 40 percent of complications occur before the age of 10 yers . The type of complication and the clinical presentation vary greatly with age - gastrointestional bleeding and intestinal obstruction are more common in children .Many authors recommend routine diverticulectomy,but some authors illustrate that the risk of diverticulectomy outweighs the benefits for some patients. From August 1999 to August 2001 identification of Meckel´s diverticulum was performed on all children ( 4 to 18 years of age ) undergoing laparoscopic appendectomy.Retrograde examination of the ileum in 34 children identified Meckel´s diverticulum in 5 cases ( almost

15 percent incidence! ). In the same period we had 2 children with symtomatic Meckel´s diverticulum - gastrointestinal bleeding ( 2 yers old boy ) and intussusception ( l8 months old girl ). We performed laparoscopic diverticulectomy by stapler ,but in case of intussusception it was necessary to carry out wedgeshaped resection (broad-based diverticulum).We had no complications. Results: We recommend active identification of Meckel´s diverticulum in all children undergoing laparoscopic procedure (appendectomy). Diverticulum resection is not always required , because the risk of developing symptomatic problems is decreased with age. It is appropriate to carry out diverticulectomy in children under 10 yers age.


p11. LAPAROSCOPIC DRAINAGE AND EXCISION OF INTRA-ABDOMINAL CYSTS

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

Objective: In children presenting with intra-abdominal cysts, as demonstrated on ultrasound, the conventional treatment is with laparotomy. This presentation describes the laparoscopic treatment of intra-abdominal cysts.

Method: A 5 day old boy presented to an out-patient clinic with a mobile abdominal mass. This had previously been demonstrated on antenatal ultrasound at 19 weeks and reported a simple cyst. Further ultrasonic examination revealed a mobile cyst in the right upper quadrant measuring 4 cm in diameter and freely mobile, thought to be mesenteric or an enteric duplication cyst.

One neonate with an ovarian cyst and one older child with an ovarian dermoid were also included in the study and the departmental experience of intra abdominal cysts is reviewed.

Results: Under general anaesthesia laparoscopy demonstrated a spherical duplication cyst on the anti-mesenteric aspect of the small bowel. Using a spinal needle this was drained and the deflated cyst was excised and removed via the umbilical port site. The child was discharged the following day. The ovarian cyst was treated in a similar manner. The ovarian dermoid was formally excised and removed within a bag via the umbilical port site.

Conclusion: Some varieties of intra-abdominal cysts are suitable for laparoscopic drainage followed by definitive treatment,intra- or extra-corporeally thus achieving all the benefits of laparoscopic treatment over laparotomy.


p12. EXPERIENCES ON 19 CASES LAPAROSCOPE-ASSISTED SWENSON OPERATION

Li Yuzhou, Liang Jiansheng, Yao Gan, Yang Qingtang,
Department of Pediatric Surgery, No. 1 People's Hospital of Foshan.(528000), Foshan Guangdong,P.R.China

Aim: To introduce the experiences on laparoscope-assisted Swenson's operation of congenital megacolon. Method: We performed 19 cases of micro-laparoscope assisted Swenson's operations during Oct. 1999 to July 2001. Age of the patients arranged from 27 days to 18 months. Results: The 19 cases were done with assistant of laparoscope. There were minor damage to the abdominal and pelvic cavity, less bleeding, less pain, small incision, speedier recovery compared to the traditional Swenson's method. Conclusions: Part of Swenson operation can be done by laparoscope. The laparoscopic method has the advantages of speedier recovery, shorter hospitalization time and less complications. It's worthy to be populized.


p13. LAPAROSCOPIC PROCEDURES FOR MECKEL'S DIVERTICULUM PATHOLOGY IN CHILDREN

I.V.Poddoubnyi M.D., A.F.Dronov M.D., A.N.Smirnov M.D., N.A.Al-Mashat M.D., P.M.Yaroustovskyi
Russian State Medical University, Department of Pediatric Surgery, Moscow, Russian Federation

Fifty-eight patients (from 1 month to 14 years) with Meckel's diverticulum pathology underwent laparoscopy for bleeding (39 cases), for acute abdomen caused by diverticulitis or diverticulum perforation (14) or for acute bowel obstruction (5) within the period from 1993 to 2001.

According to laparoscopic findings the following surgical procedures were performed:
Open small bowel resection - 6 cases;
Laparoscopic resection of the diverticulum 52 cases with no signs of pathology in its basis and in the adjoining bowel:

  • ·ligature resection 24 patients;
  • ·resection with endostapler 26 cases;
  • ·in 2 cases - hand resection with double-row endoscopic stitch.

Three trocars (3-12 mm) were used in all cases. The operating time varied from 15 to 100 min. (average about 30 minutes). The usual hospital stay after laparoscopic procedure was 3 days.
There were no complications and conversions to open procedure, no cases of recurrent bleeding during the period of postoperative observation from 1 month to 8 years.
In our opinion laparoscopy provides the best diagnostic possibilities and effective minimally invasive surgical methods for the treatment of Meckel's diverticulum pathology in children.


p14. RETROPERITONEAL TUMOR TREATED BY LAPAROSCOPYC WAY

Polliotto SD, Staltari JC, Díaz R, Quiros D.
Clínica Colón, Mar del Plata, Argentina.

Background : retroperitoneal tumors are not common in the first two decades of life. About 75 % of them are potencially malignant.

Aim: discuss uses of laparoscopic treatment for retroperitoneal tumors.

Case report: 15-years-old girl who presented abdominal pain. Ultrasonography showed a thin-walled cystic image 3.7 cm diameter, with homogeneous content situated in the retroperitoneum, close to the tail of the pancreas. By computed tomograpyh was shown the tumor contacting the tail of the pancreas, aorta, vascular renal pedicle, and left suprarenal vein. It could not be identificated the origin of the tumor. The anatomic limits were improved by magnetic resonance. The tumor markers, and serology tests, were negative.

Results: the patient was under general anesthesia, in left lateral decubitus. A pneumoperitoneum was performed with Varess needle under 12 mmHG pressure maximun. Trocar 10 mm umbilical, (camera), 5 mm epigastric, 10 mm left flank . Disecction of the colonic esplenic angle, retroperitoneal space was open by up the upper pole renal, where the pancreas was identificated (corpus and tail) and the upper pole renal, an esferic tumoral mass was found with a good line of section, its limits were: pancreas up, aorta in the midline, low renal pedicle and lateral external suprarrenal vein. The complete excision was possible by using the armonic bistury. The extraction of the specimen was performed in a bag, through the trocar placed in the flank. Operation time was 75 minutes. There were no perioperative complications. The histopathologic examination revealed: gastric duplication cyst.

Discussion: the laparoscopic approach let us the diagnostic and treatment in a safely and efficiently way for a disease with a difficult anatomic access, with a low morbidity and soon functional recovery.


p15. VIDEO-ASSISTED TREATMENT FOR A CASE OF ATRESIA DUODENAL

Polliotto SD, Staltari JC, Moretti L
Clínica Colón, Mar del Plata, Argentina

Background: atresia is the most frequent cause of congenital bowel obstruction during neonatal period.

Objective: to study the utility of laparoscopy for the treatment of duodenal atresia.

Case report: patient 24-hours-old, with a birth weight of 2,950g, diagnosed as duodenal atresia type I. The radiography showed an image of a double bubbles. A rotegenogram contrast showed the partial obstruction.

Results: patient was under general anesthesia, in back decubitus position. Some 8 mm Hg maximum pressure pneumoperitoneum was performed. Trocar 10 mm umbilical (camera), 5 mm hipocondrius, and left flank. The laparoscopic exploration is performed from the duodenum to the colon, showed a proximal duodenum dilation, the second and third portion of the duodenum are liberated following with the complete disection of the transition segment. In that zone, we performed an skin incision of one centimeter long, and through it we made a duodenal vertical incision, and performed a V-shaped portion of the membrane is excised. The vertical incision is closed transversely whit one layer interrupted 5-0 sutures.

Operation time was 55 minutes. There were no perioperative complications. The patient was fed during the following 72 hours, and she was discharged on the fifth postoperative day.

Discussion: laparoscopic approach made it possible the diagnostic confirmation of atresia type I, performed the dissection of the bowel transition segment, locating and limitating the incision size with a safe anastomosis, low morbidity and soon functional recovery.


p16. IS LAPAROSCOPY SAFE AFTER MAJOR BLUNT TRAUMA OF THE ABDOMEN IN CHILDREN?

L Carfagna, H Steyaert, MA Lembo , JS Valla,
PEDIATRIC SURGERY FUNDATION LENVAL NICE, FRANCE

Introduction: Most of the abdominal trauma's in children are not operated. In case of hemodynamic instability or signs of peritonitis however, exploration is mandatory.

We describe 2 cases of full minimal-invasive major blunt trauma's management and discuss the feasability.

Case Reports: The first case is a 9 years old boy with peritonitis after empalement on a broom stick. Peritonitis was clinical and visible on Xrays; laparoscopy occurred 6 hours after the accident. A perforation of the sigmoid was closed and complete lavage of the abdominal cavity done. There was no drainage.

The second patient was 5 years old and transferred after delayed diagnosis (60h) of colonic perforation due to a scooter. After few hours reconditionning laparoscopy was decided. A rigth colonic flexure was sutured and covered with omentum. Lavage was complete and drainage without colostomy was decided.

Discussion: This cases are illustrations of the excellent combination between radiology and laparoscopy to manage mini-invasivally major trauma's of the abdomen. Volume and fat are not important in a child's abdomen and bowel length is short. That allows probably better exploration in comparison with adults. Magnification permits undoubtly more accurate sutures and lavage is certainly better by laparoscopy. This and a perfect antibiotic strategy decrease the need for colostomy even in delayed cases.


p17. MINIATURE ACCESS CHAIT CECOSTOMY: A NEW APPROACH TO THE MANAGEMENT OF FECAL INCONTINENCE

Joselito Tantoco MD, Marc A. Levitt MD, Guy F. Brisseau MD, Philip L. Glick MD, Michael G. Caty 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. Antegrade continence enema is a well-established procedure in the management of children with fecal incontinence. Chait and Shandling described the percutaneous approach for the management of these children. The procedure eliminated the need for an operation, can be performed under sedation and local anesthesia, and is clinically effective with minimal morbidity. However, it has several potential disadvantages. First, it is a blind procedure. Second, the cecum is not secured to the abdominal wall. Third, the procedure requires a skilled interventional radiologist. And fourth, the procedure requires two stages. Methods. Miniature access Chait cecostomy was used in 4 children with fecal incontinence. Under direct vision the cecum is identified, mobilized, sutured to the anterior abdominal wall, and with precision the Chait device is inserted. Results. The procedure permitted excellent cecal visualization and mobilization. Precise positioning of the device in the cecum was achieved. Antegrade continence enemas were performed at 10 days. The procedure was clinically effective with no postoperative complications. Conclusions. Miniature access Chait cecostomy for children with fecal incontinence is a safe option. The procedure allows excellent cecal visualization and mobilization minimizing the risk of complications. It is a single stage procedure performed by the surgeon, the same person responsible for long-term bowel management.


p19. LAPAROSCOPY IN DISEASES INVOLVING THE GREATER OMENTUM

J. Waldschmidt,M.D., R. Lohse,M.D., L. Meyer-Junghaenel,M.D.
St. Joseph Hospital, Dpt. of Pediatric Surgery, Berlin, Germany

Diseases involving the greater omentum are very rare and are often only recognised intraoperatively. They are usually accompanied by an acute abdomen and are then an incidental finding. Our patient population of 1350 children, who underwent laparoscopy included 7 with primary diseases of the grater omentum accompanied by acute abdominal symptoms: omental cyst, lymphangioma, omental infarction, abscess, tumor and cord formation with chronic incarceration. The age ranged between one and 9 years. The diagnosis was established preoperatively only for cyst and lymphangioma. The therapeutic procedure was dependent on the findings. The cyst was fenestrated by laser and the lymphangioma was resected. In the tumor (rhabdomyosarcoma), we only took a biopsy. Partial resection of the greater omentum was performed for omental infarction and chronic omental abscess. The cord formation with chronic hernial incarceration was resected by laser. None of the children had intra- or postoperative complications, no drainages were necessary.

Keywords: laparoscopy, omental disease, children


p20. LAPAROSCOPY FOR INTESTINAL BLEEDING IN INFANCY

IE Willetts, K Elmalik, SS Marven,
Dept. Paediatric Surgery, Sheffield Children's Hospital, UK

AIMS: The localisation of the site of origin of gastro-intestinal bleeding in childhood is difficult. It has been suggested that laparoscopic examination of the abdominal viscera should precede upper gastro-intestinal endoscopy in investigation protocols, as the latter may lead to significant intestinal distension of the bowel with insufflated air, rendering subsequent safe laparoscopy difficult. We report a case of significant gastro-intestinal bleeding in an infant in whom initial laparoscopy necessitated subsequent upper GI-endoscopy and laparotomy during the same anaesthetic to successfully excise an intra-gastric lesion. The place of laparoscopy in the investigation protocol of childhood gastrointestinal bleeding will be discussed.

METHODS: A four month old male infant presented acutely with profound anaemia (Hb 3.9g/dl) and melaena stool. He was otherwise well and had no significant past medical history. Notably there was no history of haematemesis. Following resuscitation, ultrasound examination of the abdomen was performed (normal) and he proceeded to laparoscopy under general anaesthesia. At operation a small vitelline remnant was identified but the proximal intestinal lumen was found to contain altered blood. Subsequent upper GI-endoscopy demonstrated the presence of a polypoid, 5cm diameter mass arising from the posterior wall of the body of the stomach, associated with altered blood intraluminally. Exploration of the abdomen through a left upper quadrant transverse muscle-cutting incision was performed, gastrotomy allowing complete excision of the intra-gastric mass.

CONCLUSION: Initial upper GI-endoscopy followed by subsequent endoscopic retrieval/laparotomy would have avoided unnecessary laparoscopy in this child. The role of laparoscopy in the investigation of GI-bleeding in childhood needs clarification.


p21. ENDOSCOPIC SURGERY OF DIAPHRAGMATIC ANOMALIES : A MULTICENTRIC STUDY OF THE GROUPE D'ETUDE EN COELIOCHIRURGIE INFANTILE (GECI). PART 1 : POSTEROLATERAL HERNIAS (BOCHDALEK) AND EVENTRATIONS

P.Philippe,MD., F.Becmeur,MD., N. Bax,MD, D.Vanderzee,MD., H.Allal,MD., O.Reinberg,MD., M.Lima,MD., Y.Heloury,MD., F.Berchi,MD., F.Bawab,MD., J.S.Valla,MD., M.Robert,MD., F.Varlet,MD.
CHL,Luxembourg;CHU Hautepierre, Strasbourg;WKZ,Utrecht; CHU,Montpellier;CHUV,Lausanne; CHU,Bologne; CHU,Nantes; HUMI12Octubre,Madrid; CHU,Besançon; Fondation Lenval,Nice; CHU,Tours; CHU,Saint Etienne

Introduction :To evaluate its feasibility, we reviewed the thoraco- and laparoscopic access to diaphragmatic posterolateral hernias of Bochdalek (PLH) and eventrations (EV) in a multicentric study.

Method and procedures : In a retrospective study within GECI, we collected 67 patients with 70 laparo- or thoracoscopic operations from 18 centers. Among those were 31 PLH (22L,9R), age 15mo.(2d. to 13y.), weight 7.6kg (2.5 to 20kg),including 10 neonates(NN), and 10 EV (3L,7R), age 10.5mo.(5d. to 32mo.), weight 7kg (2.5 to 16kg), including 5 NN. Data analysed were age, weight and symptoms, success or conversion, causes for conversions.Results : In the PLH group, were 9 thoraco- and 24 laparoscopies (2: thoraco and laparoscopy).The procedure was successful in 20/31 (64.5%). In neonates, 5/10 (50%) were converted. In the EV group, were 6 thoraco- and 4 laparoscopies, with 6 conversions. Conversions were due to: lack of visibilty / working space (11), irreducibility (5), size of the defect(1), bowel injury(1), ventilation difficulties(1).The repair was by direct suture or plication (20) or with a patch (4). Operating time was 97 min(45-205), hospital stay 5.7 d.

There was 1 reccurence. There were no adverse effect of the endoscopic attempt in 17 converted patients. Conclusions: Endoscopic repair of the diaphragm is possible in 2/3 of the patients. With no adverse effects of a conversion on outcome, and its well-known advantages, a minimally invasive access deserves further trial and evaluation.


p22. THREE TROCARS NISSEN FUNDOPLICATION IN A CHILD WITH LIMITED ACCESS

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

Introduction Our usual technique of Nissen fundoplication requires 4 ports. We had to treat a 3year-old neurologic child with intractable emesis and recurrent ab ingestis pneumonia in which a percutaneus endoscopic gastrostomy (PEG) and a ventriculo-peritoneal shunt (VPS) hindered access to abdominal cavity.

Methods A 10mm trocar was positioned in epigastrium for camera with "open" tecnique, and two 5mm trocars in upper left abdomen and in xifoid region respectively. With two devices the lesser omentum could be opened without injuring hepatic branch of vagus, the distal esophagus dissected and a retroesophageal window created handling with two retractors. A 360° wrap was fashioned and fixed to the esophagus acting with a supplementar tool through the channel of an operating laparoscope (STORZr.).

Results Fundoplication was performed laparoscopically respecting both PEG and VPS. The procedure took about 120min. There were no intra-peri-operative complications and the child enjoyed a quick bowel function recover.

Conclusions Laparoscopic exploration and unusual surgical tricks seem to be justified before giving up the chance of endoscopic surgery even in patients with limited access.


p23. FOLLOW.UP OF VLS TREATED GERD THROUGH A NEW PARAMETER: AREA UNDER H+

Garzi A, Zagordo L, Ferrucci E, Messina M.,
Department of Pediatric Surgery-University of Siena

Objectives: we compare the data provided by 24-hour esophageal pH monitoring pre and post-operatively in a group of patients who have had a surgical treatment for Gastro-Esophageal Reflux Disease (GERD) and in a group of controls. We used both conventional parameters and the area under the curve of hydrogen ion activity (AUH+), a new parameter describing the real acid exposure, considering the length and the depth of acidity fall. Methods: 15 controls and 27 patients with GERD (15 without endoscopic esophagitis and 12 with Savary I-IV endoscopic esophagitis or erosive GERD) were enrolled in a study based on pre and postoperative 24 hour pH monitoring, to compare reference values through Receiver Operating Characteristic (ROC) discriminant analysis and Mann-Whitney test. Results: Best ROC cutoff values were AUH+=103.7 mmol/l/min with sensitivity 76.7% and specificity 93.3% for not erosive GERD patients and AUH+=114.1 mmol/l/min with sensitivity 100% and specificity 96.7% for erosive GERD. The sensibility increases of 16.7% for not erosive GERD and of 10% for erosive GERD against the most used conventional parameter (DeMeester score). Postoperatively, the whole series were under AUH+=103.7 mmol/l/min. Conclusions: AUH+ could be a reliable clinical aid being a more sensitive parameter in discriminating negative or positive pediatric patients with or without esophagitis. Furthermore AUH+ is the most reliable parameter to evaluate the outcomes after medical and surgical treatment.


p24. LAPAROSCOPIC GASTROSTOMY TUBE PLACEMENT: IS THERE A BEST TECHNIQUE?

Stella Lavor,M.D., Monowat Ngerncham,M.D., Keith Georgeson, M.D., Carroll Harmon, M.D.,Ph.D.
Department of Surgery,Division of Pediatric Surgery University of Alabama at Birmingham, AL, USA

Introduction: Because of frequent complications many surgical techniques have been described for pediatric gastrostomy tube placement. The purpose of this study was to determine the outcomes for three different laparoscopic gastrostomy techniques performed by one surgeon. Methods: A retrospective 144-chart review, 1992 1996, was undertaken. Data included patient demographics, neurologic status, indication for operation, concomitant fundoplication, OR time and complications. Laparoscopic surgical techniques included 1)T-fastener, 2)Stamm-type gastrostomy through a trocar site and 3)trans-abdominal wall/stomach 'U' stitch. Fisher's Exact Test was used for statistical analysis with p<0.05 considered significant. Results:Technique frequency was 29% T-fastener, 31% trocar site and 40% U-stitch. Neurologic impairment was noted in 79% with fundoplication performed in 92%. In gastrostomy alone cases OR times were similar for U-stitch and trocar technique but longer for the T-fastener technique (28 and 31 vs 42 min). Minor complications were similar with the U-stitch (16%) and trocar site (18%) techniques but less frequent in the T-fastener (11%) technique (p=0.01). Major complications (re-operation/hospitalization) were similar between techniques (14-22%, p=0.35). Conclusion: The laparoscopic gastrostomy approach has not eliminated frequent postoperative problems (25-40%). The 'T-fastener' technique may have fewer minor complications than the trocar site or U stitch method.


p25. LAPAROSCOPIC REDUCTION OF GASTRIC VOLVULUS AND REPAIR OF GIANT HIATAL HERNIA IN A NEWBORN

Timothy D. Kane, M.D. and Keith E. Georgeson, M.D.,
University of Pittsburgh Medical Center and Children's Hospital of Pittsburgh, Pittsburgh, PA and University of Alabama at Birmingham School of Medicine and Children's Hospital of Alabama, Birmingham, AL

Gastric volvulus in the newborn period is a rare clinical entity. Most often these infants have associated diaphragmatic defects. We report a three week old term infant weighing 2.4 kg who was referred for failure to gain weight, tachypnea with feeds, and frequent emesis. A chest X-ray demonstated an intrathoracic stomach and barium swallow confirmed this as well as revealing no obstruction. Laparoscopic evaluation revealed a large hiatal hernia, normal diaphragms, and an inverted, completely intrathoracic stomach. Reduction was achieved using one 5 mm and two 4 mm trocars. Laparoscopic hiatal hernia repair with placement of a primary gastrostomy button was performed. The infant fed well for only one week after which she developed recurrent emesis. Studies revealed hypertrophic pyloric stenosis. Laparoscopic pyloromyotomy was completed and the infant did well for the next month. Recurrent episodes of emesis and failure to achieve sustained weight gain influenced the decision to perform a laparoscopic Nissen fundoplication. The infant was gaining weight and thriving following the final procedure. Gastric volvulus with large hiatal hernia is amenable to laparoscopic management and repair. The complexity of this case did not preclude the performance of multiple subsequent minimal access approaches to correct problems such as pyloric stenosis and gastroesophageal reflux which developed.


p26. LAPAROSCOPIC ASSISTED GASTRIC TRANSPOSITION IN INFANT: CASE REPORT

Montinaro L,M.D.; *Esposito C,M.D.;**Bartoli F,M.D.; Paradies G,M.D.; Leggio S,M.D.,
Division of Paediatric Surgery, University of: Bari, *Catanzaro and **Foggia, Italy

INTRODUCTION: We report on a female infant born with oesophageal atresia type III who underwent primary repair. Few months later, she developed signs of disfagia associated with failure to thrive. An upper GI study showed a patent anastomosis with an extended stenosis (about 5 cm.) between the middle a lower oesophagus. On these basis, we decided to go for oesophageal replacement by intrathoracic gastric transposition. At the time of surgery, she was 10 months old with a weight of 5 kgs.

METHODS AND PROCEDURES:The laparoscopic approach was similar to that routinely used for correction of G-E reflux. The first step was to divide the short gastric vessels between clips and to cut the gastro-phrenic ligament. Then, the gastro-oesophageal junction and the oesophagus were dissected up into the mediastinum through the diaframmatic iatus. Also the little gastric curvature was mobilised by dividing the left gastric ligament preserving the gastric artery. Finally, the oesophageal iatus was dilated to facilitate the passage of the stomach. After the abdominal time was performed by laparoscopy, the operation was completed through the right thoracotomy. The post-operative outcome was uneventful and, actually, the child is feeding and growing well.

CONCLUSIONS: The development of sophisticated laparoscopic techniques and the acquisition of expertise allow to modify standardised surgical approach to execute unusual operative procedures safely with good results in infants.


p27. THE LEARNING CURVE FOR LAPAROSCOPIC PYLOROMYOTOMY - IMPACT ON GENERAL SURGICAL RESIDENCY EXPERIENCE

David Naar, M.D., Paul A. Brisson, M.D., Neil R. Feins, M.D., Haroon I Patel, M.D.
Floating Hospital for Children, Childrens Hospital(*), and Boston Medical Center(#), Boston MA

Background: Laparoscopic Pyloromyotomy(LP)is feasible and safe.Improved cosmesis, decreased surgical stress,earlier postoperative recovery,and possibly shorter hospitalization are potential advantages over the traditional open procedure(OP).The impact of this procedure on general surgery resident training,especially in programs with pediatric surgical trainees,has not been evaluated.We reviewed our early experience with LP,specifically focusing on the impact of the learning curve upon surgical training.

Methods: Retrospective review of all pyloromyotomies performed between July 97-June 98.

Results: Twenty nine patients were identified -9 LP and 20 OP.The groups were matched for body weight,age,clinical and physiologic status and size of the pylorus.The learning curve accounted for longer operative times in the early LP cases. There was no statistical difference in time to full feeds,length of stay,and complications. Postoperative emesis was lower in the LP group.The general surgery resident did 75% of OP cases but no LP cases.

Conclusions: The learning curve for LP results in fewer cases being available for surgical residents.The impact of this and other newer minimally invasive techniques on resident operative skills appears to be significant.Residents are unlikely to perform an adequate number of procedures to achieve competency,placing children who might require these procedures in the community at risk.


p28. PRELIMINARY COMPARASON OF LAPAROSCOPIC VS. OPEN NISSEN FUNDOPLICATION IN PATIENTS WITH CONGENITAL HEART DISEASE

Sanjeev A. Vasudevan, M.D.; Vinod H. Thourani, M.D.; Mark L. Wulkan, M.D. ,
Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston

Purpose: To compare the feasibility, risks, and overall efficacy of open with laparoscopic Nissen fundoplication in infants with congenital heart disease.

Methods: A retrospective analysis was performed on 38 infants with congenital heart disease requiring antireflux surgery from June, 1994 to April, 2000. Twenty-eight patients underwent open Nissen fundoplication (Open); 10 patients underwent laparoscopic Nissen fundoplication (Lap). Patient demographics and intraoperative and postoperative outcomes were evaluated. Student's T-test was utilized for statistical analysis, and P<0.05 was considered statistically significant.

Results: The groups were of similar gestational age and birth weight (Lap 37+/-3 wks, 3.2+/-0.7 kg; Open 36+/-5 wks, 2.6+/-0.9 kg). The age and weight at time of surgery were similar (Lap 32+/-45 wks, 5.6+/-2.5 kg; Open 58+/-61 wks, 6.6+/-3.6 kg). Mean operative time was not statistically different (Lap 98+/-37 mins; Open 94+/-24 mins). Time to full feeds and length of stay were not statistically different (Lap 6+/-7 days, 8+/-8 days, Open 6+/-5 days, 7+/-4 days). 1 patient in the Open group sustained transection of the anterior vagus nerve. There was 1 post-op death in each group.

Conclusion: Laparoscopic Nissen fundoplication in infants with congenital heart disease is a safe, feasible surgical technique with results comparable to open Nissen fundoplication.


p29. HOW THE PROCESSUS VAGINALIS OBLITERATES

Bahr M, Korn St, Schier F
Department of Pediatric Surgery, University Medical Centre Jena/Germany.

Objective: The mechanism of physiologic closure of the processus vaginalis (in boys) is still unknown. The only data available stem from historic series of post mortem examinations of children.

Methods and procedures: During routine laparoscopies for inguinal hernias in children (n= 247; aged 3 weeks to 13 years, median 1.8 years) the processus vaginalis was evaluated and its configuration recorded.

Results: In 5% of hernia patients, a partially occluded processus can be observed. (The majority of patients have either wide open or completely closed processus). As to be demonstrated by several video recordings, the processus occludes in the form of segmental narrowings, much like an hour-glass.

Conclusions: Routine laparoscopy answers the open question of how the processus physiologically closes. The mechanism also explains the occurrence of hydroceles and funiculoceles, the latter being entrapments of fluid between two segmental closures.


p30. LAPAROSCOPIC APPROACH OF A CLOACAL ANOMALY ASSOCIATED WITH VAGINAL AGENESIS

M.M.Bailez and J. Solana
Pediatric Surgery , J.P.Garrahan Htal BS AS. Argentina

Present a rare spectrum of cloacal malformation and the role of laparoscopy in its diagnosis and treatment. Introduction: . Laparoscopy gives an optimal view of the pelvis and helps to achieve a low dissection of the fistula with minimal trauma. We previously (Ipeg 2001) reported our experience with laparoscopy combined with total urogenital sinus mobilization for the treatment of cloacas with a high abdominal rectum. We now present a patient with a cloaca associated with vaginal agenesis and the important role that the initial laparoscopic approach played in its diagnosis and reconstruction. Case Presentation : A 4 years old female was admitted for cloacal reconstruction. She had a normal sacrum and kidneys and a sigmoid diverted colostomy. Distal cologram showed a very short tracted sigmoid and an intermediate rectum ending in the cloacal channel . No vaginal structures were seen with xray contrast studies. Under general anesthesia , an endoscopic study of the cloacal channell showed a good bladder neck and proximal urethra and a rectum ending 3 cm from the cloacal opening No vaginal opening was recognized. Laparoscopy showed two solid lateral mullerian remnants and confirmed uterovaginal dysgenesis . It also demonstrated clearly that a very short distal sigmoid was left. We decided then to leave the rectum as a vagina and descend the proximal sigmoid colostomy to the perineum . The external sphinther was recognized and incised from the perineum. Under laparoscopic vission an expandable sheat trocar was introduced behind the rectum to achieve sigmoid descent..Colostomy was taken down and a stappler was placed distally ,leaving the rectum as a blind ending vagina.The proximal sigmoid was brought down to the perineum using the perineal port. Anoplasty was completed and the cloacal channell was mobilized and opened to create a "vaginal" wide opening . As there wasn´t any suture line except for anoplasty left in the perineum , a protective colostomy was not opened..Operative time was 5 hours. We started feeding her after 72 hours postop. After 4 months of follow up she presents voluntary bowel movements without constipation or soiling. Discussion: .Only 12 out of 160 females with anorrectal malformations assisted in our hospital had complete uterovaginal dysgenesis . Only 2 of them were cloacas. Leaving the rectum as a vagina has been previously described in patients with a rectovestibular fistula and vaginal agenesis. A combined initial endoscopic and laparoscopic assessment of the anomaly permitted a less invasive and time consuming approach in a case that would be a candidate to start with redoing "the inadequate colostomy".


p31. COMBINED HISTEROSCOPIC AND LAPAROSCOPIC TREATMENT OF OBSTRUCTED UTERINE DUPLICATIONS

Bailez M. *, Gutierres V.* Videla Rivero L , Viglioco J. , Pisani A and Rodríguez J. L.
Pediatric Surgery Garrahan Htal and Gynecology of Callao Surgical Institute. Bs As . Argentina

Present a rare obstructed supracervical defect of lateral fusión of the mullerian ducts and its minimally invasive treatment. Introduction: Obstructed lateral fusion uterovaginal anomalies result from a failure of fusion of both mullerian ducts associated with one side failure of the lumen to comunicate with the outside. The most frequent variety is the double uterus with an obstructed hemivagina and ipsilateral renal agenesis ( Wunderlich-Heryn-Werner syndrome) which treatment is endovaginal resection of the septum, creating one single vagina. A higher level of obstruction (uterine cervix) is rare and its symptoms very acute because of the loss of the reservoir-like action of the duplicated vagina to accommodate the menstrual blood. Patients & Methods : Five adolescents with this anomaly were assisted between July/2000 and August/2001 Their mean age was 13,5 years. They were admitted with acute abdominal pain . All of them had severe dysmenorrhea ; normal external genitalia and a patent vagina. There was no endovaginal "bulging" and ultrasound showed normal kidneys and an asymmetric uterine duplication. MRI showed an asymetric hematomethra in all of them but misdiagnosed an hematosalpinx as an hematocolpos in 1patient. One patient had a previous failed endovaginal instrumentation .We started doing a laparoscopy to confirm the suspected anomaly and evaluate endometrosis , followed by an operative hysteroscopy through the nonobstructed uterus to resect the duplicated uterine walls (septum), creating one single uterine cavity. The laparoscope was left in place to monitor the hysteroscopic operation and reduce the risk of perforation. The intense of the laparoscopic illumination was ocassionaly reduced to allow to judge the thickness of the uterine walls as the operation progressed. Results: The procedure was completed sucessfully in 4 patients with a mean operative time of 90 min .The non obstructed uterus was thin and displaced by the obstructed and caution needs to be taken not to perforate its walls. On the other hand the septum was very thick and it was hard to reach the obstructed cavity , specially in the first case. One patient required an open surgery because we were not able to dilate her uterine cervix to introduce the hysteroscope. She underwent a conventional metroplasty and salpingoplasty because of a severe associated hematosalpinx . Mean hospital stay was 1,5 days. Patients are asyntomatic , with regular menses and no ultrasonic evidence of obstruction after a mean follow up of 7 months. Conclusion: These patients represented the 23,8% % of uterovaginal anomalies of lateral fusion (Class III) assisted in our institution ( 21 p). We point out the absence of associated renal anomalies and the utility of MRI.

Although there are no previous reports of this minimal invasive approach in pediatrics , we consider this preliminary data suggests that it may be included as a valid option to treat and preserve an obstructed mullerian structure.


p32. LAPAROSCOPIC OVARIAN TRANSPOSITION TO PRESERVE FERTILITY IN PEDIATRIC PATIENTS PRIOR TO PELVIC IRRADIATION

Bartsch, Leah A MD; Smith, Baird M MD; Donaldson, Sarah S MD; Marina, Neyssa MD; Tang, Nelson MD  

Background: preserving fertility is an important consideration in children needing pelvic irradiation for cancer therapy. Transposing ovaries out of the designated radiation field may be an effective method of protecting gonadal function in these children. Laparoscopy provides a minimally invasive method of achieving these goals.

Case report: four children underwent laparoscopic ovarian transposition to remove ovaries from the field of pelvic irradiation. Two patients had hodgkin's disease, one patient had pelvic rhabdomysarcoma, and one patient had a cerebellar medulloblastoma requiring cranio-spinal irradiation. Ovaries were transposed to two locations: medially behind the uterus to protect them from irradiation of pelvic nodes or laterally above the pelvic brim to protect them from central radiation. Patients ages ranged from 1 to 18 years. Results: markers placed on the transposed ovaries showed they were indeed shielded from irradiation. There were no operative complications and patients were discharged from our service the day following surgery. At this time pain was well managed with po medications, patients were tolerating regular diets, ambulating, and voiding spontaneously. In all four cases, blood loss was minimal. Subsequent return of menstruation was observed following radiation.

Conclusion: laparoscopic ovarian transposition is a safe and effective option for preserving fertility in pediatric cancer patients who require pelvic irradiation.


p33. ONE-TROCAR RETROPERITONEOSCOPIC VARICOCELECTOMY: OUR EXPERIENCE

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

Introduction: We present our experience with the one-trocar retroperitoneoscopic varicocelectomy.

Methods and procedures: 41 patients with left varicocele underwent one-trocar retroperitoneoscopic varicocelectomy (January 1999-2001). Mean age was 12.1 years (range 6-18). The patient was placed in flank position. Through a 1.5 mm sub-costal incision and muscle splitting the retroperitoneal space was reached. The Gerota's fascia was opened, a 10 mm ballooned Hasson trocar introduced and the pneumoretroperitoneum established (15 mmHg). Retroperitoneal dissection was completed by a blunt tip dissector through the operative telescope. Spermatic vessel were identified, dissected and cut after bipolar coagulation. All patients had a doppler study at least 6 months after the operation. Retrograde spermatic venography was performed for varicocele persistence.

Results: In 7 patients (17%) no identification of the spermatic vessels was achieved and conversion to laparoscopic transperitoneal approach was performed. In the 34 patients completed retroperitoneoscopically the mean operation time was 25 minutes (range 15-50). Mean hospital stay was 2.3 days. Mean follow-up was 13 months (range 6-24). Five patients (14.7%) had varicocele persistence. Venography showed collaterals in 2 cases. One patient (2.9%) had mild bilateral hydrocele.

Conclusions: Our experience show that one-trocar retroperitoneoscopic varicocelectomy is a good mini-invasive alternative for varicocele treatment.


p34. MINI-LAPAROSCOPIC PALOMO'S PROCEDURE BY BIPOLAR COAGULATION FOR VARICOCELE IN CHILDREN AND ADOLESCENTS

Francesco De Peppo MD., Paola Marchetti MD., Emanuela Ceriati MD., Francesco Randisi MD, Giuseppe Broggi MD and Massimo Rivosecchi MD
Department of Pediatric Surgery , Department of Radiology Bambino Gesu Children's Hospital , Rome , Italy

Aim : to evaluate the effectiveness and complication rate of mini-laparoscopic approach in the treatment of varicocele.

Methods : From January to September 2001, 17 children with left side varicocele underwent a mini-laparoscopic procedure according to Palomo's Technique. Mean age was 13 years (8-17 yrs). Varicoceles were classified as grade II in 3 cases and grade III in 14 patients. Under general anesthesia , a 5 mm port was inserted under direct vision through the umbilicus and pneumo-peritoneum was established. Two 3 mm re-usable working ports were inserted in the right lower quadrant and in left flank. Peritoneum overlying spermatic vessels was incised 3-4 cm above the vas. The internal spermatic vein(s) and artery were mobilized , accurately coagulated with a 2.7 mm bipolar forceps and finally divided. Local anesthesia at port sites, was performed to reduce p.o. pain.

Results : No perioperative complications occurred in this series. Mean operative time was 35 minutes ( 20 to 52 min.). All but two patients were discharged within 8 hours from intervention. Six months after surgical procedure a color-Doppler sonography was carried out. No recurrent varicocele or testicular volume reduction was detected. Postoperative hydrocele was observed in two patients and in a case required a surgical procedure. Esthetic results were excellent.

Conclusion : Mini-laparoscopic approach for treatment of varicocele seems to be as safe and effective as open procedure. Larger series are necessary to compare incidence of complications of these different procedure.


p35. LAPAROSCOPIC CLOSURE OF PATENT PROCESSUS VAGINALIS AND TRANS-SCROTAL ORCHIOPEXY FOR UNDESCENDED TESTIS

Masao Endo, MD,PhD, Etsuji Ukiyama, MD, Fumiko Yoshida, MD
Department of Pediatric Surgery Saitama Municipal Hospital

The principle of the orchiopexy for undescended testis consists of closure of the patent processus vaginalis (PPV) and placement of the pedunculate testis in the dartos pocket. Laparoscopic PPV closure with an Endoneedle conducted us to its application to orchiopexy for nonpalpable and palpable testis. The procedures are performed with a 5-mm telescope through the umbilicus. The testicular vessels and the seminal cord are prepared for stretching by coagulator / endoscissors through a 15-G sheath needle inserted just above the internal inguinal ring (IIR). A 1.5-cm skin incision is made at the uppermost portion of the scrotum and a dartos pocket is made downward to the bottom. The testis is drawn out from the scrotal skin incision through the lowest portion of the PPV. The pedicle is detached from surrounding tissues high at its neck, and stitched to the dartos layer under gentle traction of the testis downward. While, the PPV is closed extraperitoneally with the Endoneedle. The testis is placed in the dartos pocket after confirmation of blood stream by Dopp flowmetry. Since May 2000, this procedure has been carried out in 10 boys with undescended testis, including two intra-abdominal testes. In all cases the testis was delivered successfully. No testicular atrophy or hernia formation has occurred, and cosmesis in all patients is excellent.

This procedure may provide one-stage diagnostic and therapeutic maneuver for all nonpalpable and palpable undescended testes.


p36. LAPAROSCOPIC NEPHROURETERECTOMY- A MODIFIED TECHNIQUE

P. Godbole MBBS, M.S., A. Najmaldin M.D.
Department of Paediatric Urology, Leeds Teaching Hospitals Leeds, U.K.

Introduction: We present our technique of laparoscopic nehroureterectomy and its advantages over conventional laparoscopic techniques.

Methods: Eighteen consecutive children(10 boys, median age 5y) undergoing laparoscopic nephroureterectomy were studied prospectively. All had a poorly/nonfunctioning kidney and a dilated ureter.The technique involves creating a peritoneal window directly over the kidney, mobilisation of the kidney, ligation of the vascular pedicle, extraperitoneal placement of the kidney and its extraperitoneal retrieval via the iliac fossa cannula site. In case a concomitant bladder is performed, the specimen is retrieved extraperitoneally via the lateral aspect of the pfannenstiel incision. No preoperative stenting or enema is required.

Results: Early conversion was required in one child with an undiagnosed horseshoe kidney, recurrent perirenal sepsis and ureterostomy.The median operating time was 92 minutes (66-120 ) and median hospital stay was 2 days (1-4). Analgesia was for a maximum of 12 hours postoperatively.There were no laparoscopy related complications and the cosmetic results were excellent. All children remain well at between 1 to 7 years follow up.

Conclusion: Our technique of laparoscopic nephroureterectomy is a safe and effective alternative to conventional laparoscopic and open surgery. It is particularly attractive in those patients already undergoing an open bladder procedure.


p37. ENDOSCOPIC TREATMENT OF VESICOURETERAL REFLUX IN CHILDREN: HAVE 505 PROCEDURES WITH COLLAGEN TM BEEN WORTHWHILE ?

C. Gorsler, U. Huebner, H. Halsband,
Department of Paediatric Surgery, University Medical Center Luebeck, Germany

Objective: To report the clinical experience in children with vesicoureteral reflux treated endoscopically with Collagen tm.

Materials and methods: In 8 years we were performing on 192 children 505 endoscopic subureteric injection procedures for vesiculoreteal reflux with collagen.

Results: After one to 3 suburetric injections we had a success rate of 74.9 percent for either no more reflux or first to second grade reflux without symptoms. Discussed are the grade of the reflux at the beginning of the therapy and accompanying anomalies as well as the number of injection therapies and its success into regard on long time results in addition. Success was tested on persistend reflux and the necessity of operative treatment by reimplantation of the ureter as well as the number of recurrences.

Conclusions: Subureteric injection with collagen tm is safe and sufficient in the endoscopic treatment of vesicoureteral reflux in children even when it is unstable and tends to migration; under the influence of BSE crisis we are nowadays using Delfux tm for subureteral injection.


p38. LAPAROSCOPIC PYELOURETEROSTOMY

K.Selvarajan MCh, M.Ramalingam MCh, M. G.Pai MCh
K.G.Hospital and Post Graduate Institute Coimbatore,India

Introduction: Duplication of pelvis is managed according to the problems which the child has at the time of presentation. 8 months old male child with duplication of right kidney with lower moiety hydronephrotic secondary to vesicoureteric reflux was managed successfully by laparoscopic surgical technique by doing pyeloureterostomy and excising the lower ureter.

Material and Methods: 8 months old male child presented with an attack of UTI and it was investigated with ultrasound, isotope renogram,MCU and cystourethroscopy apart from biochemical tests and histopathological study of urine. It revealed refluxing (GR IV) ureterohydronephrosis of lower moiety with reduced function and normally functioning upper moiety. By laparoscopic method,the pelvis of lower moiety was anastomosed to ureter of the upper moiety (end to side) and the ureter of lower moiety was excised in toto. Post operative period was uneventful and anastomosis is functioning well.

Results: Pyeloureterostomy is reasonable technique here as the upper moiety ureter was normal (neither obstructive nor refluxing). The refluxing lower ureter was excised to prevent further damage to lower moiety. The good functioning of the anastomosis will preserve the function of the both moieties.

Conclusion: Of the options available for treatment of duplication of the kidney the pyeloureterostomy is one of the best methods. Technical expertise in doing laparoscopic method is alone a prerequiste to reduce the morbidity of open surgical method in addition to all benefits like reduced cutting of tissues while exposure, less pain, early return to activity and minimal scar.


p39. DIAGNOSTIC LAPAROSCOPY IN RECURRENT ABDOMINAL PAIN IN CHILDREN - MILIARY T.B.ABDOMEN IN RARE CAUSE FOUND

Selvarajan Krishnasamy Mch, Manickam Ramalingam, M.G.Pai, Mch,
K.G.Hospital and post graduate institute, Coimbatore Tamilnadu, India

Introduction: Recurrent abdominal pain is perplexing one and is a testing time for all pediatric surgeons in dealing with many children who have such problem. Surprises are the rule in diagnostic laparoscopy many times and miliary tubercles involving the entire peritoneum and all viscera was found in a child.

Materials and methods: 12 year old male child was suffering from recurrent abdominal problems for 8 months. No other complaints except for a poor intake of food. All investigations including x-ray abdomen and chest,haematology and mantux were inconclusive except on Ultrasound scan which showed minimal ascites and thickening of greater omentum. Diagnostic laparoscopy revealed miliary tubercles involving entire peritoneal cavity both visceral and partial peritoneum,liver, gallbladder,spleen,stomach, small and large intestines, mesentry,pelvic organs etc. Biopsy of few tubercles on the parietal peritoneum was taken and it proved to be tuberculous. Antituberculous drugs was started.

Results: Diagnostic laparoscopy is an accepted procedure for recurrent abdominal pain in children. Here the child with recurrent abdominal pain had a positive finding and that too, an unusual problem with a very rare presentation namely miliary tubercles in the abdominal cavity involving all organs and entire peritoneum. Treatment was started and child improving well.

Conclusion: The criteria to decide for diagnostic laparoscopy for recurrent abdominal pain in children is yet to be agreed upon among Pediatric surgeons, But the severity and frequency of abdominal pain should warrant diagnostic laparoscopy based on the individual surgeons assessment. Tuberculous abdomen is itself a rare cause which usually diagnosed by laparotomy in early days. Laparoscopy is a very useful tool in such rare problems where biopsy is required to diagnose as well as to treat the condition.


p40. AN AUDIT OF THE FIRST SEVEN YEARS EXPERIENCE IN EDINBURGH OF LAPAROSCOPIC LIGATION OF TESTICULAR VESSELS FOR VARICOCELE

R.B. Aldridge (Medical Student), F.D. Munro, M.D. and G.A. MacKinlay, M.D.,
The Royal Hospital for Sick Children, Edinburgh, Scotland

Objective: To review all laparoscopic varicocelectomies undertaken at the RHSC, Edinburgh, since the first was undertaken there, in 1994.

Methods: A retrospective analysis was undertaken of all the laparoscopic ligations of testicular vessels, for varicoceles, during the 7-year period. 32 patients were operated on. The average age was 160 months. Of the 32, 31 were left-sided and 1 right. Duration of operations, complication rates, recovery profiles and testicular size were examined and compared.

Results: The average operation duration was 32 minutes. 16 were undertaken as day cases and 16 as 'one-night' stays. No cases required a longer admission. There was a 0% incidence of wound infection and of laparoscopic complications.

Average follow up was 11.4 months. Prior to operation 10 cases had reduction in size of the affected testicle, but all showed improvement after vein ligation. 22 cases had normal testicular size preoperatively and all of these showed no atrophy post-operatively. Post-operatively, 5 cases (16%) developed hydroceles, which required surgical intervention. These were corrected by Lords procedure.

Conclusions: This experience shows that the results of the laparoscopic approach are comparable to those of the open approach. In this series it was shown that varicocelectomies did not cause testicular atrophy, indeed, all patients in whom there was a reduction in size of the affected testicle pre-operatively showed improvement post-varicocelectomy.


p41. AN ABSOLUTE CONTRA-INDICATION TO LAPAROSCOPIC FOWLER-STEPHENS PROCEDURE

C. Noviello M.D., C. Del Monaco M.D., A.Vessella M.D., P. Parmeggiani M.D., G.Amici M.D * and A. Papparella M.D.,
Second University of Naples, University of Ancona*, Department of Pediatric Surgery, Naples Italy

Laparoscopic one and two-stage Fowler-Stephens procedure has gained large popularity in the child for the treatment of the high intra-abdominal testis. It's largely debated which is the best technique such as testicular auto-transplant or laparoscpic Fowler-Stephens procedure . We describe a case of three years old child, where a previous bilateral inguinal exploration was negative for testes or testicular remnants. The diagnostic laparoscopy showed two iliac intra-abdominal testes with short spermatic vessels, inguinal rings closed and complete dissociation didime-epididime. A left open orchidopexy was perfomed and testicular auto-transplant was proposed for the right testes because located at 3 cm from the internal inguinal ring. The long-term follow-up (1,8 year ) of the left testis showed the testis in the scrotum with good testicular size (1,5 cm). We believe that there are two main reasons to contra-indicate the Fowler-Stephens technique: it has been showed that when a patient has undergone previous surgery the risk factor for testicular atrophy is higher than patient that has undergone first surgery. Furthermore the showed associated malformation could not permit the development of collateral blood-flow via the vasal artery, necessary for viable testis . Diagnostic laparoscopy was of great value in planning the surgical approach to known location of the testis


p42. NOVEL TECHNIQUE OF CYSTOLITHOTRIPSY FOR LARGE VESICAL CALCULUS IN CHILDREN

Manickam Ramalingam, Krishnasamy Selvarajan,
KG Hospital and Postgraduate Institute, Coimbatore,India

Objective:Large vesical calculi are difficult to manage endoscopically. We describe our technique of cystoscopically assisted suprapubic removal with minimal urethral manipulation.

Method:A seven year old boy was admitted for removal of a 7cm vesical calculus. Cystoscopy was done with an 8fr ureteroscope. Lithoclasty was attempted but the stone was wobbling around. A 12mm laparoscopic trocar was introduced into the bladder under vision. A laparoscopic grasper was passed and the stone was stabilized against the posterior wall and the stone was fragmented. Once the fragments were small enough to be held with the grasper they were further fragmented until they reached a size that was easy to retrieve the bits through the trocar. Complete removal was achieved and the suprapubic trocar was removed. An 8fr catheter was left urethrally for 2 days. There was no extravasation or other complications. The boy is doing well at 6 months followup.

The same technique has been used in two other similar situations subsequently with success.

Conclusion: We present this to highlight this technique that enables removal of large vesical calculus endoscopically without trauma to the urethra.


p43. LUMBOSCOPY ASSISTED PYELOTOMY AND PYELOPLASTY IN CHILDREN

Christos Salakos M.D., Yvelise Verney M.D. and Hervé Giard M.D.
Pediatric Surgical Department, Roubaix General Hospital - France

Lumboscopy and laparoscopy are well known techniques that provide minimally invasive access for surgeries involving the renal pelvis (pyelotomy/pyeloplasty) in children. They remain time-consuming procedures even for well-trained endoscopists due the lack of space for performing any suture. The authors report two cases, a 4 y-old girl with obstruction of the left ureteropelvic junction, and a 3 y-old boy presenting renal staghorn calculi in the right kidney. The dissection and mobilization of the renal pelvis and ureter have been easily performed by lumboscopy and they could be exteriorized through the main trocar (10mm) port. The pyeloplasty and pyelotomy, respectively, were performed in a conventional and faster way. The post-operative follow-up has been uneventfull in both cases. This technique associates the advantages of minimally invasive surgery with those of the conventional approach and it can be a valid alternative to renal pelvic procedures in children.


p44. RETROPERITONEOSCOPIC RENAL SURGERY IN CHILDREN: OUR PRELIMINARY EXPERIENCE

L.Repetto°M.D., B.Tadini°°M.D., G.L. Milan°M.D., M.Gatto°°M.D. °
U.O.A. Urology San Giovanni Battista Torino, Italy °° U.O.A. Paediatric Urology O.I.R.M.-S.Anna Torino, Italy

Introduction: laparoscopic renal surgery has become an accepted approach in adult urology. Major advances in laparoscopic surgery made it possible to perform laparoscopic renal surgery in children too. We report our experience of 12 consecutive children. Methods: from august 1999 to September 2001 12 children 12 months - 13 years old (mean age 53 months) underwent retroperitoneoscopic renal surgery. Mean body weight was 18 kg (range 9-62). All patients had benign disease, 5 multicystic kidney,6 severe reflux nephropaty with poorly functioning kidney and dilated refluxing ureter, 1lower pole renal cyst.11 nephrectomies and 1 cyst marsupialization were performed. Results: all the operations were successfully done laparoscopically, even in 3 cases in which the peritoneum was entered during creation of retroperitoneal space. Mean nephrectomy time was 110 min (range 220 - 55).Cystic marsupialization was performed in 40 minutes. Blood losses were minimal. All the patients but one were discharged on the second postoperative days. Mean follow up was 18 months (range 1-25) cosmetic results were excellent, no long term complications have been noted. Conclusions: laparoscopic retro peritoneal renal surgery is feasible even in children with minimal morbidity, post operative discomfort and short hospital stay. The previously considered disadvantages of this surgery such as operative time and technical difficulties have become less of a concern as we gain experience with this procedure.


p45. RETROPERITONEOSCOPIC PYELOPLASTY FOR PUJ OBSTRUCTION IN CHILDREN. 10 CASES WITH MORE THAN ONE YEAR OF FOLLOW UP

Valla J.S. , Carfagna L., Lembo M.A., Almohaidly M., Steyaert H.
PEDIATRIC SURGERY LENVAL FUNDATION NICE, FRANCE

Introduction : The gold standard procedure for treating pyeloureteral obstruction in children is dismembered pyeloplasty by open surgery ; mini-invasive treatments include endourologic section (impossible in infants and contraindicated in case of lower pole crossing vessels) and laparoscopic pyeloplasty. We have developped a retroperitoneal pyeloplasty in order to avoid the drawback of the transperitoneal approach.

Material : 6 girls, 4 boys. Mean age 10 years (3 to 17). All the patients were symptomatic. The diagnosis was confirmed by ultrasound and diuretic renal scann MAG 3. At the beginning of the procedure all patients underwent initial placement of an ureteral stent. The patient was placed in lateral decubitus and the retroperitoneal space entered through a 10 or 5mm incision, for a 30° telescope and two or three operating ports 3 or 5 mm in diameter. The uretero pelvic junction with any redundant renal pelvis tissu was incised and removed. The proximal ureter is spatulated. The pelvis and ureter were anastomosed using 5/0 or 6/0 polyglatin suture thread (intracorporeal knots). An ureteral stent was left in place in all cases (simple stent 5 times, JJ stent 5 times).

In one case of crossing vessels, the dissection and posterior fixation of the pelvis was sufficient to remove the obstruction.

Results : The procedure was successfull in 8 patients. Two cases needed a conversion. The mean operative time is 3 hours and a half. The mean hospital stay is 4 days ; ureteral stent was removed at day 3 post op. in case of simple stent (5 cases) and 4 to 8 weeks post op in case of JJ stent (5 cases). We have had one urinoma after ureteral stent removal at day 3 which was treated by JJ stent. All patients have had ultrasound and renal scann with a mean follow up of 16 months (10 to 36) No clinical or radiological failure was recorded.

Discussion : Retroperitoneoscopy gives a good vision of the pathological lesions, specially in case of crossing vessels (3 cases). One of the difficulties is now to present and stabilise the pelvis and ureteral wall for suturing. Some tricks have been described and our preference is to temporarly fix theses structures to the psoas muscle. In this preliminary experience an ureteral stent was left in all cases, instead of only 15% of our open pyeloplasties.

Conclusion : Retroperitoneoscopic pyeloplasty is possible and is more logical than the transperitoneal one. But this procedure remains technically challenging and we do not recommend this technique before 6 months of age.

Perhaps in the future, robotic assisted surgery and new tissu sealing technique could allow to perform an ideal pyeloplasty without stent in day surgery.


p46. SEMINAL VESICLE CYST WITH IPSILATERAL RENAL AGENESIS : ANTENATAL DIAGNOSIS AND POST NATAL LAPAROSCOPIC EXCISION

Valla J.S. , Carfagna L., Almohaidly M., Lembo M.A., Steyaert H.,
PEDIATRIC SURGERY LENVAL FUNDATION NICE, FRANCE

This case report is illustrated by a videotape (3').

Most of the seminal vesicle cyst are reported in adults and treated by conventionnal surgery throught transvesical or perineal or sacral approach. We reported a case of a seminal vesicle cyst which is diagnosed antenatally at 22 weeks and we performed laparoscopic removal of the cyst at 6 months of age.

In this male fetus, the ultrasound exam at 22 week has discovered two anomalies on the left side : renal agenesis and 17mm unilocular paravesical cyst. Following ultrasound before and after birth have confirmed theses findings, the baby is healthy, no urinary infection, no other malformation. Retrograde cystography is normal and DMSA scintigraphy has proved left renal agenesis. Two diagnosis are evoked : seminal vesical cyst and dysplastic multicystic kydney in an ectopic position ; according to the family, so the baby is supervised by serial ultrasounds and 6 months later the cyst has increased to 25mm of diameter and that was an indication for removal which is begun by a cystourethroscopy : bulge of the posterior urethra and uprising of the bladder floor on the left side. Laparoscopy throught a 5mm transombilical port for the 30° telescope and two 3mm operating port allowed to remove the cyst and to preserve the vas deferent by leaving a narrow strip of the cyst wall along the vas. The recovery was unevent-full and the infant discharged home within 48 hours. Three months later the child is asymptomatic.

In conclusion laparoscopic technique could be useful for excision of seminal vesicle cyst as it is the case for mullerian remnants.


p47. A MINIMALLY INVASIVE APPROACH TO PELVI-URETERIC JUNCTION OBSTRUCTION IN CHILDREN.

A. Graham Wilkinson, M.D. , Gordon A. MacKinlay, M.D.
The Royal Hospital for Sick Children, Edinburgh, Scotland

Objective: To determine whether balloon-burst pyeloplasty with stenting is a realistic alternative to surgery in pelviureteric junction obstruction in children.

Materials and Methods: 11 children aged between 1.6 years and 10.6 years underwent 12 procedures of balloon-burst pyeloplasty. Three children had undergone failed surgical pyeloplasty, one procedure was performed following recurrence of PUJ obstruction 1 year after balloon-burst pyeloplasty and the others were primary procedures. Approach to the PUJ was antegrade in 7 procedures, retrograde in one procedure and combined in 4 procedures. Balloon sizes ranged from 5mm to 10mm. A variety of stents were placed including double pigtail, straight antegrade and nephroureteric configurations, size 8-12 French.

Results: There were no major complications although 3 children suffered urinary tract infection. All procedures were successful with improvement or normalisation of the dilatation measured on ultrasound and improvement in drainage on Tc99m-MAG3 renography.

Conclusion: Balloon-burst pyeloplasty with temporary stenting is a reliable and safe procedure and is a realistic alternative to surgical pyeloplasty. Considerable reduction in hospital stay is possible in some cases.


p48. LAPAROSCOPIC EXCISION OF A PROSTATIC UTRICLE IN A CHILD.

IE Willetts, JP Roberts, AE Mackinnon
Department Paediatric Surgery, Sheffield Children's Hospital, Sheffield, U.K.

We present a successful minimally invasive approach for excision of a prostatic utricle cyst in a child. Prostatic utricle cysts result from incomplete degeneration of Mullerian duct structures and occur most frequently in males with perineal or peno-scrotal hypospadias. Utricular cysts may present with various signs and symptoms including urinary tract infection, pain and post-void incontinence, a palpable abdominal mass or recurrent epididymitis. Treatment is reserved for symptomatic cysts and various techniques have been described including transurethral deroofing, endoscopic incision or surgical excision by suprapubic, posterior and midline transvesical approaches.

METHODS: A 4 years old boy presented with recurrent left epididymitis. At birth he was noted to have agenesis of the corpus callosum and a peno-scrotal hypospadias, repaired at 2 years of age. Micturating cysto-urethrogram demonstrated a large cystic swelling posterior to the bladder, arising from the posterior urethra, which filled on micturition. Following antibiotic therapy, elective excision of the prostatic utricle cyst was performed under general anaesthetic. Initial cysto-urethroscopy demonstrated a small opening on the verumontanum leading into a large utricle cyst; a 9F Wolff cystoscope was left in the utricle to aid identification. A 5mm telescope port was placed at the umbilicus with one 5mm trocar in the left and one in the right flank. A 3mm trocar was placed in the right iliac fossa to act as a bladder retractor. The bladder was emptied by suprapubic puncture to allow its anterior retraction, producing excellent visualisation of the utricle cyst. The cyst was readily dissected to its neck where it was ligated with a 'surgiloop', transected and retrieved via the umbilicus. The child was discharged to home on the second post-operative day without complication. Cystourethroscopy and further MCUG four months after surgery revealed no residual utriculus and no further episodes of epididymitis have occurred to date (14 months follow-up).

CONCLUSIONS: Laparoscopic excision is a safe and viable alternative to open procedures in the surgical treatment of symptomatic utricle cysts in childhood. The presence of a cystoscope aids identification of the utricular remnant.


p49. ERGONOMIC DIFFERENCES BETWEEN LAPAROSCOPIC INSTRUMENTS DESIGNED FOR PEDIATRIC PATIENTS VS ADULT PATIENTS.

Trudy A.G. Kenyon, RN, David Bliss, MD, Tom Curran, Lee L. Swanström, MD,
Department of Minimally Invasive Surgery, Legacy Health System, Portland, Oregon

Ergonomic issues related to Minimally Invasive Surgery (MIS), have influenced the physical and mental workload for both surgeons and staff. Instruments designed for the adult patient's abdomen may not provide the dexterity or economy of motion required in a delicate neonate. Do we need to change the mentality of one-size fits all? We studied the "manual movement task" in handling adult or standard laparoscopic instruments compared to pediatric laparoscopic instruments.

We constructed a mathematical model based on the assumption of a 3.5 kg neonate abdomen with a pneumoperitonium. We compared the kinematics created by the length of two laparoscopic instruments. The criteria included review of industry standards for shaft lengths of typical laparoscopic instruments for standard and short lengths. Shaft lengths (SL), fulcrum distance and the entire maneuverability of the instruments at a fixed fulcrum were measured and compared. The upper and lower arm movements were noted.

The standard SL was 32cm compared to 21cm for the short SL. The Fulcrum point was 5cm fixed from predicted abdominal wall to tissue target. The excursion ratio of the tip to handle maneuverability in the standard SL was 5.5 : 1, compared to 3.2 : 1 in the short SL. The short SL improved the maneuverability relationship by 42%. Longitudinal axis was 46.5cm for the standard SL and 27.5cm for the short SL for an improved kinematics of 41%

Conclusion: Does one size fit all? No. Pediatric laparoscopic instruments are ergonomically preferred for the smaller patient. The reduction in gross motion to execute the same task is statistically significant, with an overall improvement of economy of motion by 41% and improved excursion ratio of 42%.


p50. AN OPERATING THEATRE BASED RADIO NETWORK FOR BROADCASTING LIVE ENDOSURGERY ON A HOSPITAL IT NETWORK

Sean S Marven MB ChB, Lewis Thompson, Paul Wells, Hany GabraMB BCh, David Bywater, Russell Banks
Sheffield Children's Hospital Sheffield S10 2TH

Objective- We evaluated the quality and safety of a hospital IT network to broadcast live dual video streams of paediatric endosurgery via an operating theatre based radio network

Methods - A broadcast quality video camera (JVC, MS4) was used to record an external image and a standard video endoscope camera (Karl Storz) for the internal image. Two PCs (Tiny 1.4 GHz Pentium 4 ) were used to digitise the images (Windows Media Encoder, Microsoft). Signals were relayed via a 10 Mb radio network (Enterasys) to a further PC (Tiny 450 MHz Pentium III) at another location. A media server set up to accept live streaming video (Windows 2000 Media Services, Microsoft) and customised media software (Windows media player, Microsoft) was used to allow two simultaneous views on the screen from the two separate cameras. The output was viewed on a networked PC and a 42 inch Plasma screen (Sony).

Results - Use of a radio network within the operating theatre can be reliable without interference with other medical equipment. Each image was of 320x240 pixel size and found to be smooth and of good quality with an approximate time delay of five seconds.

Conclusions - Live endosurgery can be relayed via a radio network from within the operating theatre using standard network components, PC based media stations and plasma screen without the need for expensive wideband cabling. This offers the potential of archiving and viewing live endosurgery for minimal cost and effort.


p51. THE NEXT GENERATION MINIATURE ACCESS PYLOROMYOTOMY SPREADER

Tantoco JG, Levitt MA, Brisseau GF, Caty MG, 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. The original Ramsted pyloromyotomy and Benson spreader are time tested. Miniature access pyloromyotomy for infants with pyloric stenosis have comparable operative times and rate of complications with open pyloromyotomy. Surgeons are always striving to improve miniature access surgery by developing new techniques and instruments. We describe our use of a unique miniature access pyloromyotomy spreader. Methods. A miniature access pyloromyotomy spreader modeled after the Benson spreader was used in 8 infants with pyloric stenosis. The spreader has the following unique features; it is slim, it opens with double action, it is serrated on the outside, and can be used trocarlessly. Results. The use of the miniature access pyloric spreader facilitated the performance of the pyloromyotomy procedure. Operative time was improved and complications avoided. Its slim size allowed the spreader to easily fit into the myotomy incision. Serrations on the outside of the spreader permitted enough friction to prevent the instrument from sliding. The double action mechanism allowed equal distribution of force on both sides of the myotomy. Trocarless introduction decreased abdominal wall trauma and improved cosmesis. Conclusions. The miniature access pyloromyotomy spreader is a very useful instrument in miniature access pyloromyotomy. Use of the spreader improved surgical precision, operative time, and avoided complications.


p52. SUPRASELLAR ARACNOID CYST: ENDOSCOPIC TREATMENT

José Hinojosa MD, Javier Esparza MD, Maria Jesus Muñoz MD, Angel Muñoz MD, Francisco Berchi MD
Department of Pediatric Surgery, Hospital 12 de Octubre, University Complutense Madrid/Spain

Arachoid cysts account for only 1 % of all intra-cranial space-occupying lesions in adults supra-sellar cysts represent 9 % of all the arachnoid cysts while in pediatric population this percen-tage reaches 15 %. The authors present a serie of seven consecutive patients with diagnosis of suprasellar arachnoid cyst membranes, with or without associated ventriculostomy of the 3rd ventricle. Preoperative symptoms improved in all the patients and five out of seven remain shunt free.1 patient mantain a cystoperitoneal shunt and another one, previously shunted, remain shunt dependent. In spite of being a problem relatively common in daily neurosurgical practice there are still a number of questions to be solved concerning pathogenesis and evolution,natural history and treatment.Located in the suprasellar cistern and closely related to the ventricular system,suprasellar arachnoid cysts conform a perfect indication for endoscopic treatment.

The development:and spreading of neuroendoscopic techniques have surpassed the standard micro- surgical approaches as an elective treatment. However there are still contraversy on the management of associated hydrocephalus,need for cysto-peritoneal shunt after endoscopic fenestration of superiority of ventriculocystocisternostomy over simple ventriculocystostomy. The clinical presentation and postoperative evolution are commented with discussion.


p53. VENTRICULOPLEURAL SHUNT - THORASCOPIC PLACEMENT OF THE DISTAL CATHETER: TECHNICAL CASE REPORT

S.Kurschel M.D. *, H.G.Eder M.D.*, J.Schleef M.D.**
Departement of neurosurgery*, Departement of pediatric surgery** Karl-Franzens-University, Graz Auenbruggerplatz 29 A-8036 Graz

Introduction: Ventriculopleural shunting is usually reserved for patients with limited options for shunt revisions, when conventional sites like the peritoneal cavity and the right atrium are used up or unavailable.

Methods and Procedures: We report the case of a 16 year old boy with a posthemorrhagic hydrocephalus, who required numerous shunt procedures. At the age of 6 years a ventriculopleural shunt was inserted by a intercostal thoracotomy, 4 years later a replacement of the distal catheter was necessary. Recently he was presented again with shunt malfunction due to displacement of the pleural catheter. Placement of the distal catheter was performed under direct thorascopic vision by a peel-of-needle into the unscarred pleural cavity dispite two previous pleural procedures.

Conclusions: Ventriculopleural shunting is an alternative option for problematic patients. Thorascopic placement of the distal catheter is a safe and efficient technique even in patients with prior surgical interventions.


p54. NEUROENDOSCOPIC THIRD VENTRICULOSTOMY AS A FIRST-CHOICE APPROACH FOR HYDROCEPHALUS IN CHILDRE

Rogon Jacek, M.D., Ph.D. ,
CLINIC OF PAEDIATRIC SURGERY, GDAÑSK MEDICAL UNIVERSITY, GDAÑSK, POLAND

Neuroendoscopic third ventriculostomy (NTV) is a method of treatment of hydrocephalus in children. The technique can be used in hydrocephalus of any aetiology. NTV may be secondary or primary, depending on whether the patient had been previously treated with shunt, or not.

Since 1999, NTV (either primary or secondary) has been performed in thirty-six children, aged from 3 days to 14 years. Non-functioning shunts were removed during secondary NTV.

The following criteria for NTV were met, based on the MRI scans:

  1. the foramen of Monro and the third ventricle greater than 5 mm;
  2. no scarring of subarachnoid space below the third ventricle;
  3. the tip of basilar artery situated close to mammillary bodies.

The access to the ventricular system for NTV is the right pre-coronal burr-hole. A caniula for endoscope is then insert into the lateral ventricle. Using flexible, 3.5-mm endoscope with working channel and the ME2 monopolar, 0.9 mm wide electrode, the floor of third ventricle is perforated in order to create a new passage for the CSF from ventricular system into basal cisterns.

More than 50% of patients treated with NTV did not require any further operation. Implantation or reimplantation of shunt was done between 8 and 20 day after NTV failure.

NTV is a single procedure for at least half of the children with hydrocephalus. It does not preclude eventual shunt implantation in the case of failure.


p55. LAPAROSCOPIC OESOPHAGOPLASTY IN CHILDREN:A CASE REPORT

Hossein Allal, Manuel Lopez,Dominique Forgues, Mahfoud Moudar,Pascal Gres,Marie Pierre Guibal,René Benoît Galifer
Department of Pediatric Surgery. Lapeyronie Hospital Montpellier. France

Laparoscopic replacement of the esophagus is reported in adult surgery but not in pediatric's. The aim of this report is to show that it's possible technically to replace laparoscopically the esophagus by the colon. The patient is a 9 old boy with an esophageal extending caustic stricture. The patient is in supine position, the surgeon between the leggs, assistant in right and left side We used a 7 mm telescope with 30° vue, and 4 operative trocars. First the esophagus is dissected through the mediastin, then resected from the cervicotomy.The colon is exposed to be resected: selection of the left colic artery. The transverse and descending colon is resected with stappler and passed through the mediastin. The colon is anastomosed to proximal esophagus isoperistaltically. The cologastric and colocolic anastomosis are performed using resorbable running suture. We finished the procedure by a pyloromyotomy and gastrocolique antireflux. Operative time was 10 hours without peroperative complication.


p56. LAPAROSCOPIC TREATMENT OF EXTRALUMINAL DUODENAL DIVERTICULUM IN CHILDREN

Francisco Berchi MD, Indalecio Cano MD,Araceli Garcia MD, Maribel Benavent MD,Elena Portela MD,
Department of Pediatric Surgery Hospital 12 de Octubre University Complutense Madrid/Spain

A 14 year old boy was referred to our hospital with a history of intermittent abdominal pain of 4 months evolution.Gastrointestinal barium upper series demonstrated a duodenal diverticulum located at external of the 3rd duodenal portion.At duodenoscopy,a duodenal diverticulum was detected.Laparoscopic approach was decided.The boy was placed in supine,in a head-up position slightly rotated to the left.Insertion a 5mm 30degrees telescope through the superior umbilical fold was performed.A 12mmHg pneumoperitoneum was established.2 working ports were inserted, 1 in the left flanc and 1 on the right at the umbilical level.A 4th port was placed under the xiphoid for a liver elevator.Mobilization of the transverse colon and the lateral wall of the 2nd and 3rd portions of the duodenum were necessary in order to localized the diverticulum.The diverticulum was completely dissected from the surroundings structures and divided by means of an endoGIA.The patient returned to full activity within 3 days and has remained asymptomatic during a 1 year follow-up.Duodenal diverticulum are malformations rarely described in children.They can cause abdominal pain,obstruction,ulcers,and hemorhage and may perforate Diagnosis is made by endoscopy or upper gastrointestinal series,and surgical treatment is indicated in symptomatic patients.Laparoscopy can be a safe approach in the treatment of extraluminal duodenal diverticulum.


p57. LAPAROSCOPIC DUODENODUODENOSTOMY FOR TREATMENT OF ANNULAR PANCREAS IN CHILDREN

Francisco Berchi MD , Indalecio Cano MD, Araceli Garcia MD, Maribel Benavent MD, Elena Portela MD,
Department of Pediatric Surgery Hospital 12 de Octubre University Complutense, Madrid/Spain

Annular pancreas is a congenital disorder usually diagnosed in newborns as an intestinal obstruction.When occurs in older infants or adults symptoms may mimics those of peptic ulcer.The standard operative approach for the treatment of annular pancreas is laparotomy with duodenal by-pass.We report one case of laparoscopic duodenoduodenostomy as the definitive treatment of annular pancreas in children.An 10-year old boy with a suspect diagnosis of annular pancreas was prepared for surgery.The patient was placed in supine position,and a 12 mm fourth laparoscopic ports were required to perform a duodenoduodenostomy. The patient did well postoperatively.An endoscopy revealed a narrowing at the level of the anastomosis,requiring dilatation.He was subsequently discharged home on a regular diet and remained asymptomatic during one year follow-up.Laparoscopic duodenoduodenostomy is a viable approach to treat duodenal obstructions.It provides definitive treatment while preserving the benefits of minimally invasive surgical techniques in the pediatric patient.


p58. POST-LAPAROSCOPIC SPLENECTOMY THROMBOCYTOPENIA

Peter Borzi , Deborah Bailey. Therese Nano.
Royal and Mater Childrens Hospitals Brisbane Australia

The advantages of a minimal access approach to haematological disease in children have been well established with reduced analgesic requirements, rapid mobilization and quick convalescence. Doubts have been raised about the efficacy of detecting accessory spleens and its impact on natural history of haemolytic disorders such as Idiopathic Thrombocytopenic Purpura (ITP) postoperatively.We present our experience of Laparoscopic Splenectomy(LS) for ITP in children

From June 1993 to June 2001 one surgeon has performed 89 LS. 42 children had recalcitrant ITP as the indication for surgery. The age range was 9 m to 15 years (mean 8.5 yrs) and preoperative weight of 11 kg to 97 kg(mean 47kg). LS was performed as a 4 port approach with visualization at the umbilicus (30 degree scope) , epigastric and left dorsal/flank 5mm ports and a 5/12mm retrieval port in the left iliac region or higher depending the size of the child.

There were no conversions The operating times were ranging from 55 to120 min (mean 75 min). One misfire of the linear stapler at the splenic hilum was retrieved laparoscopically. 4 children had complications ( pneumonia, umbilical port site infection,

Ilioinguinal nerve hypoaesthesia, retrieval site hernia). With a minimum follow-up of 6 months the lowest postoperative platelet count was recorded. 38 had count > 100,000 +. 2 were totally asymptomatic with counts of 65,000 and 89,000 and 2 children had < 50,000 platelets. Both of these children were symptomatic : one spontaneously after 2.5 yrs and the other with viral illness within 6 months post-operatively. The first child was found to have accessory splenic tissue in the greater omentum successfully removed laparoscopically with follow up to 1.5 years with count of > 150,000. The second child had 5 accessory spleens at LS and counts fluctuate but she remains asymptomatic to 4 years postoperatively

LS for ITP secures a >90% reversal of thrombocytopenia but longterm followup is required to detect any residual symptomatic accessory spleens


p59. MINIMAL-INVASIVE ADHESIOLYSIS USING ONE-TROCAR-TECHNIQUE

Ulf Buehligen  

In spite of every possible effort postoperative adhesions after surgical interventions haven`t lost their immense importance. In many cases even multiple revisions have to take place. The slighter the operating trauma and the wound, the smaller is the probability of fresh adhesions.

Due to this reason the one-trocar-technique in 5mm was tested at laparoscopical re-interventions. These technique used optics with integrated working channel in 3,5mm device. The access with this combinated trocar takes place through the navel by mini-laparotomy. It is possible to investigate the abdomen and to work at the same time and to carry out an adhesiotomy if necessary. The use of 3,5mm instruments under laparoscopically circumstances allowes a subtile hemostasis. Other entrance ways and trocars can be economized.

Conclusions

The 5mm technique can be used in combination with 3,5mm instruments. The option to enlarge the intervention by extra trocars is kept further on. Other possible usages exist in diagnostical explorative laparoscopy. Punctures, excisional biopsy and gain of abdominal fluid are also easilly made possible without additional arrangements.


p60. DIRECT VISUAL RETROPERITONEAL ACCESS TECHNIQUE USING AN OPERATIVE LAPAROSCOPE

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

Introduction: Different retroperitoneoscopic accesses have been described. They all imply blind retroperitoneal dissection. We describe a technique that allows to create a good retroperitoneal working space under direct vision.

Methods and procedures: From January 1999 to July 2001 we performed 56 retroperitoneoscopic procedures (50 varicocelectomies, 3 nephrectomies, 1 nephroureterectomy, 2 renal biopsies). Mean age was 11,9 years (range 3-18). The patient is placed in flank position; a 1,5cm transverse incision is made below the apex of the 12th rib. Muscles are bluntly dissected and the Gerota's fascia is opened. A 10mm ballooned Hasson trocar is inserted and CO2 insufflated to the pressure of 15mmHg. The retroperitoneal dissection is performed under endoscopic vision by an endoscopic blunt tip dissector introduced through a 10 mm operative laparoscope.

Results: In 49 (87.5%) patients retroperitoneoscopic procedure was performed successfully. In 4 patients out the varicocelectomy group, there was a peritoneal tear, that needed conversion to laparoscopy in 2 cases, as well as in 5 other patients in whom spermatic vessels were not identified, at the beginning of the learning curve.

Conclusions: Our technique allows to create a good retroperitoneal working space under direct vision ensuring safe and accurate identification and dissection of retroperitoneal organs with minimal complication rate related to the access technique, even for major urological procedures


p61. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN CHILDREN

HOS Gabra , SS Marven, A Sprigg, WEG Thomas, J Walker
Department of Paediatric Surgery and Radiology, Sheffield Children's Hospital, Sheffield , UK

Introduction: A retrospective review of the indications,success rates and the complications of endoscopic retrograde cholangiopancreatography (ERCP) in Paediatric age group.

Methods: Charts for patients who had ERCP performed at our unit between 1990 and 2001 were all reviewed. Patients demographic, clinical presentation, indications, ERCP findings, complications, and follow up were recorded and analysed.

Results: Thirty three ERCP procedures were attempted in 28 patients.It included 14 boys and 14 girls, whose age ranged from 2 to 16 years (median = 10 years). All procedures whether diagnostic or therapeutic were performed by an experienced endoscopist.The indication for ERCP was either for Hepato-biliary or pancreatic pathology. Findings included Choledocal cyst (n=5), Sclerosing cholangitis (n=5), duodenal duplication (n=2), normal anatomical findings (n=15) and one patient had therapeutic stenting due to lymphoma involving the head of the pancreas. Radiographs of the relevant ducts were achieved in 29 patients (88%). Post ERCP complications consisted of pancreatitis (n=3). Follow up ranged between 260 months with no morbidity or mortality related to the ERCP procedure.

Conclusions: We conclude that, ERCP is a useful diagnostic tool in the paediatric age group.The complications rate post ERCP is comparable to adults. ERCP is a safe diagnostic procedure if the patients are carefully selected and if the procedure is performed by an experienced endoscopist.


p62. WHAT IS THE TRUE CLINICAL INCIDENCE OF BILATERAL PRESENTATION IN INGUINAL HERNIAS?

B. Haluk Guvenc M.D., Selami Sozubir M.D., Gulsen Ekingen M.D., Melih Tugay M.D., Mevlit Korkmaz M.D., Ayse Tuzlaci M.D.
Department of Pediatric Surgery, Kocaeli University School of Medicine, Kocaeli / TURKEY

Diagnostic video-endoscopic evaluation of the contralateral patent processus vaginalis (cppv) is believed to lessen the risk of a probable iatrojenic cord injury, by decreasing the number of unnecessary inguinal explorations. In the present study, the search for the true incidence of bilateral presentation in inguinal hernias, repaired with and without diagnostic laparoscopy is evaluated.

In a randomized, prospective study we evaluated and treated 319 consecutive inguinal hernia cases (M: 257, F: 62), 1 mo-14 y (mean, 3.4 year) since March 1998. 42 bilateral and 161 unilateral presentations were treated using conventional technique. Diagnostic laparoscopy was performed through the ipsilateral hernia sac in the remaining 116 (M: 86, F: 30). All of the detected cppv underwent open exploration.

An overall evaluation illustrates a 21 % bilateral presentation rate with 67 cases. The incidence of initial clinical bilateral presentation is 13 %. Six cases (4 %) out of 161 presented later with a metachronous hernia. Thus, we may speak of a cumulative 15 % clinical incidence. We found a cppv in 19 (16 %) cases.

The difference in between our metachronous hernia and positive cppv incidence numbers (4 16 %) shows that we may be over-correcting some of the cases that might never present later as a clinical hernia. According to our study speaking in terms of true clinical presentation, our estimation of 21 % bilateral presentation rate seems far from being correct.


p63. LAPAROSCOPIC HELLER ESOPHAGOMYOTOMY IN A 7 YEARS OLD WITH ACHALASIA

B. Haluk Guvenc M.D. , Levent Avtan M.D.*, Gulsen Ekingen M.D., Selami Sozubir M.D., Necati Gunaltay M.D.**, Ufuk Senel M.D.
Departments of Pediatric Surgery, Kocaeli University School of Medicine & General Surgery*, Istanbul University School of Medicine, Pediatrician** Kocaeli / TURKEY

Achalasia is a rare motor disorder of the esophagus presenting with esophageal obstruction, usually accompanied by defective esophageal peristalsis and uncoordinated tertiary nonpropulsive waves. Surgical treatment is based upon relaxation of the lower esophageal sphincter. We report a seven-year old, suffering from achalasia treated with laparoscopic Heller esophagomyotomy without simultaneous fundoplication.

A 7-years old girl was admitted with dsyphagia, vomiting, coughing, weight loss and substernal pain. The diagnosis of the pediatrician was confirmed by repeat barium swallow and esophageal manometry. Defective esophageal peristalsis with elevated pressure and incomplete relaxation of the lower esophageal sphincter was present during swallowing. Patient was fed via NG tube for two weeks prior to surgery. The procedure was completed successfully using minimally invasive technique without any complications.

Patient was relieved of symptoms and tolerated oral feedings on the third postoperative day and was discharged on the fourth. Postoperative screening has shown that the patient is free of gastroesophageal reflux.

Laparoscopic Heller esophagomyotomy is a complex and difficult operation, but can safely be performed. The need for a simultaneous antireflux procedure remains to be seen.


p65. NEW TECHNIQUE OF KNOTTING IN PAEDIATRIC LAPAROSCOPIC SURGERY.

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

Introduction: Equipped with laparoscopic suturing and knotting is invaluable for any paediatric laparoscopic surgeon since there is very limited space in abdominal cavity in children to overcome the difficulty in knotting, a new method,the CIRCLE LOOP-TECHNIQUE has been tried and found to be very useful.

Materials and methods: In all cases of Paediatric laparoscopic surgery where suturing and knotting was applicable, CIRCLE LOOP-TECHNIQUE was applied In C-LOOP-TECHNIQUE, c-loop is formed to make part of the circle intially and the completing the circle with the other instrument. Such knotting involves wide range of movements and it is difficult when there is limited space. Instead, a circle loop is formed with long thread and other instrument is introduced through the circle to catch the small end of the suture material to form the knot. Here no necessacity for rotatory movements to make a knot.

Results: The time taken to complete the knotting is considerable reduced with circle loop-technique. In addition the cumbersome nature and sometimes,helpless situations in performing knotting is overcome with circle loop-technique.

Conclusion: The knotting is a cumbersome one in paediatric laparoscopic surgery. The difficulty due to limited space in children. Any technique which involves least range of movements is definitely advantageous in knotting. In that way, circle loop-technique is highly useful in performing easy knotting.


p66. SURGICAL ROBOTICS: CREATING A NEW PROGRAM

Scott Langenburg, M.D., Mustafa Kabeer, M.D., William Lyman, Ph.D., Greg Auner, Ph.D., Lawrence Fleischman, M.D., and Michael Klein, M.D.
Children's Hospital of Michigan, Detroit, Michigan .

Objective: To share our recent experience in developing and implementing a program for computer assisted robot-enhanced surgery.

Methods and Procedures: Minimally invasive surgery has revolutionized our approach to the surgical patient in the last decade. Our vision is that robotic surgery will allow us to do more complex minimally invasive procedures on smaller patients. We defined a core of individuals who shared our vision: pediatric surgeons, our research director, a biomedical engineer and physicist, and our chief executive officer. We identified those who were presently working with robotics. After comparisons and site visits we chose a single corporate partner, not just to purchase instrumentation but to continue research and development of equipment and surgical techniques. Short term and long term educational, research, and business plans were developed. Our business and research plans were shared with our hospital administration and our hospital board of trustees to garner support.

Results: Hospital and private donor support have allowed creation of a robotic minimally invasive surgical suite in our operating room and our research building. Our pediatric subspecialty colleagues have begun utilizing our suites.

Conclusions: The key elements in developing a new program are to define a core group of committed individuals, define your vision, and create partners and garner financial support with a sound educational, research, and business plan.


p67. LAPAROSCOPIC REPAIR OF DIAPHRAGMATIC DEFECTS

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

OBJECTIVE: To report that surgical correction of congenital or acquired diseases of the diaphragm in children may be performed with video-assisted techniques.

METHODS: Patients: 12 children form 1 day to 7 years treated consecutively in a 2 years period. Indication: a) Congenital Eventration in 4 patients (2 left and 2 right ) b) Congenital Diaphragmatic Hernia in 4 patients c) Paraesophageal Hernia d) Hiatus Hernia e) Morgagni Hernia f) Phrenic nerve paralysis; all with one patient each.

Technique: Approach was laparoscopic, using three to five ports depending on the etiology of the defect. In most of the cases no chest tube was left.

RESULTS: All patients where successfully treated using a laparoscopic approach. No complications where observed. One patient (CDH) was converted to an open procedure. Mean operative time was of 155.5 minutes (120 to 300 minutes). Mean hospital stay was of 6.4 days (2 to 20 days).

CONCLUSIONS: Laparoscopic approach of the diaphragm seems to be an easy and reliable procedure that has all the benefits of these techniques. We believe that in a near future, almost all of the diaphragm-related pathologies will be liable to laparoscopic or thoracoscopic repair.


p68. LAPAROSCOPIC GASTROPEXY WITH ESOPHAGOCARDIOPEXY FOR THE SURGICAL TREATMENT OF GASTRIC VOLVULUS IN CHILDREN

Mario Mendoza-Sagaon MD, Alexandre Darani MD, Olivier Reinberg MD.,
Centre Hospitalier Universitaire Vaudois. Lausanne, Switzerland

The aim of this study was to evaluate the results of a laparoscopic gastropexy (GP) with esophagocardiopexy (ECP) in children with gastric volvulus. The files of all children with gastric volvulus being operated laparoscopically with a GP and ECP in our institution were analyzed. Nine children were included in our study. Range of age was between 1 and 11 months. Symptoms included sudden postprandial abdominal pain, vomit and in 2 patients apneic episodes associated with cyanosis, pallor and hypotonia. Diagnosis was established with upper GI series. Organo-axial gastric volvulus was found in all cases. Laparoscopic GP with ECP was performed with a 8-mmHg CO2-pneumoperitoneum using 3-mm instruments and a 4-mm scope (25 degrees). Time of surgery was between 60 and 180 minutes. One conversion was performed. Postoperative antireflux treatment was continued for 1 month in all children. Follow-up ranged between 1 month to 3years. To date, 6 patients are free of symptoms without antireflux treatment and 3 are still under antireflux treatment. Parents of all children are very satisfied with postoperative esthetics. Laparoscopic GP with ECP is a good option for the surgical treatment of organo-axial gastric volvulus in children.


p69. PEDIATRIC OMENTAL INFARCTION

Gregory T. Banever, M.D., Michael E. Ganey, M.D., Kevin P. Moriarty, M.D. , Richard A. Courtney, M.D.
Department of Surgery, Division of Pediatric Surgery, Baystate Medical Center Children's Hospital, Tufts University School of Medicine, Springfield, Massachusetts, USA

Objective Primary segmental infarction of the omentum is an infrequent cause of acute abdominal pain in children. We describe our experience with 7 children.

Methods A retrospective chart review at a tertiary referral center for 2001.

Results Seven patients, 5 boys and 2 girls, presented at age 4 to 13 years old (average 8.7 years). Four patients' weights were >95%, with the lowest being 73%. All experienced right lower quadrant pain of 18 to 96 hours duration. WBC counts were 7,800 to 16,200, and one child had fever. Two ultrasounds were performed for appendicitis, with one false positive and one non-visualized appendix. In one case, CT scan revealed non-mesenteric intra-abdominal fat streaking suggesting omental infarction. Six of seven patients' preoperative diagnoses were acute appendicitis. All underwent partial omentectomy and incidental appendectomy. Four cases were laparoscopic, two open, and one converted to open for concern of bowel injury. Pathology revealed normal appendices and acute hemorrhagic omental infarction. Two cases of umbilical port site cellulitis resolved with antibiotics. Patients were discharged home on the first or second postoperative day and were doing well at final follow-up of one to three weeks.

Conclusions Primary omental infarction is a rare cause of acute abdominal pain in children that is often misdiagnosed as acute appendicitis. Laparoscopy is an excellent diagnostic and therapeutic approach for these often overweight patients.


p70. SELECTIVE USE OF LAPAROSCOPIC APPENDECTOMY IN PEDIATRICS

Michael V. Tirabassi, MD, Gregory Banever, MD, Kevin Moriarty, MD , David Tashjian, MD, Stanley Konefal, MD, Richard Courtney, MD, Barry Sachs, MD,
Department of Surgery, Division of Pediatric Surgery, Baystate Medical Center Children's Hospital, Tufts University School of Medicine, Springfield, MA

INTRODUCTION Laparoscopic appendectomy(LA) has gained wide spread acceptance as a safe and effective treatment for appendicitis. Little evidence exists regarding selective use of LA on length of hospital stay(LOS) and operative time(OT).

METHODS Retrospective review of 165 charts for pediatric appendectomies in 1989(before our use of LA) and 1999 by one group of pediatric surgeons.

RESULTS In 1989, 72 appendectomies were performed(31 females, 41 males). Mean age and weights were 10.3 years and 41 kg. 46(64%) of appendices were acute, 15(21%) were ruptured, and 11(15%) were normal. Mean LOS was 5.0 days. Mean OT was 66 minutes. In 1999, 93 appendectomies were performed (47 females, 46 males). Mean age and weights were 11.8 years and 38.4 kg. 54(58%) LA were performed in 1999. 48(52%) were acute, 27(29%) were ruptured, and 18(19%) were normal. Mean LOS was 5.2 days. Mean OT was 81 minutes. In 1999, perioperative complications were seen in 8/39(20%) OA and 2/54(4%) LA (all ruptured). There was no significant difference in the mean LOS (p=0.82), but an increase in mean OT of 15 minutes (p=0.00078). For ruptured appendixes in 1999, complications with LA were decreased(P<0.05), mean LOS was decreased from 11 to 6 days(p=0.06), and mean morphine requirements were decreased from 1.5 to 0.6 mg/kg/LOS(p=0.03).

CONCLUSIONS The selective use of LA in our practice has significantly decreased our complications, while it has increased our mean operative time negligibly.


p71. DEVELOPING MINIMALLY INVASIVE SURGERY

Alp Numanoglu M.D . Alastair Millar M.D. Rob Brown M.D. Heinz Rode M.D.
Department of Paediatric Surgery University of Cape Town and Red Cross Children's Hospital Rondebosch Cape Town South Africa

Introduction. Our 300 bed hospital performs 8000 operations per year with extreme pressure on operating time. Modern endoscopic equipment became available in January 2001. Training was obtained from short endoscopic courses without on site mentorship

Material and methods. We review our experience in endoscopic surgery since 1999 to identify the initial use, difficulties and changes of indications in these operations.

Results. Fifty procedures were performed. (8/1999, 14/2000, 28/2001) Types of surgery were; assessment of undescended testes (18), appendicectomy (4), diagnostic endoscopy and biopsy(6), Tenckhof catheter re-positioning (3), trauma (diagnostic 2, bowel repair 1), thoracoscopic sympathectomy (3), cholecystectomy (3), other (10). The conversion rate was 20% of which 4 were converted to laparoscopic assisted mini-laparotomies, 5 were found to be difficult cases for our endoscopic experience and one distal oesophageal perforation occurred during Nissen fundoplication.

Conclusion: Since January 2001 there has been more than 100% increase in endoscopic surgery. With careful selection of patients and procedures and increased experience endoscopic surgery is becoming established in our institution. A high conversion rate was expected as more complex procedures were attempted. Our major problems are lack of mentorship and operating time.


p72. PAED - LAP MANIA !! SIGNIFICANCE OF HANDS - ON ENDOSURGERY COURSES FOR PAEDIATRIC SURGEONS?

Jahoorahmad Z. Patankar Ms.MCh. , Shyam S. Borwankar MS.MS., Hemanshi S. Shah MS. MCh., Yatindra Kashid MS
Department of Paediatric Surgery, Seth G.S.Medical College & Seth G.S.Medical College, Mumbai, INDIA

Currently there are no certified Hands-On course specific for Paediatric Endosurgery in India. Nevertheless Hands-On course in endoscopic surgery for paediatric surgeons is being held at various centres in India; throughout the year almost at monthly intervals. What is the real significance of these courses and what are their objectives? What is the likely outcome?

It is imperative that an in-depth assessment of the requirements and contents for a Hands-On course be conducted; preferably by a responsible unbiased authority. This could be achieved by surveying the vast number of participants of the course. The survey should consist of:

  • Length of the Course
  • Contents/Syllabus
  • Safety Aspects - both Anaesthetic & Surgical
  • Live Demonstrations/Videotapes
  • Invivo/Invitro Procedures
  • Instrumentation
  • Fees and so on

CONCLUSION: Strict guidelines should be observed while undertaking such courses.


p73. LAPAROSCOPIC RESECTION OF BILIARY CYSTS IN CHILDREN: ABOUT TWO CASES

C Piolat (MD), C Jacquier (MD), M Cartal (MD), C Durand (MD), F Nugues (MD), D Pasquier (MD), JF Dyon (PhD)
Pediatric Surgery, Pediatric Anesthesiology, Pediatric Radiology, Department of Pahology, University Hospital of Grenoble

Aim of the study. Biliary cystic hamartoma are rare in childhood. Surgical resection allows to prevent complications and represents the only way to bring histological diagnosis. The aim of this study is to report two cases of biliary cysts in infancy treated by laparoscopy.

Case reports. Diana, a six-month-old girl, presented a sixty-millimetre hepatic cyst prenatally diagnosed. Morgane, a two-year-old girl, presented a forty-millimetre hepatic cyst localized in the fourth segment and accidentally detected on abdominal sonography performed for hyperthermia. Nuclear magnetic resonance study was carried out. Both children underwent laparoscopic resection. Histology confirmed biliary cysts. Follow-up was uneventful with a four months passing.

Discussion. Biliary cystic hamartoma are generally asymptomatic and discovered fortuitously into ante or postnatal. Complications were reported for bulkiest. Current radiology (sonography, nuclear magnetic resonance) allows to confirm the diagnosis by eliminating the differential diagnoses. Preventive resection makes it possible to confirm the histological diagnosis. It is as well as possible carried out by laparoscopy, technique seldom brought back in the paediatric literature.

Conclusion. Early diagnosis, possibly prenatal, of the biliary cysts in children must lead to their resection. Laparoscopy represents a very advantageous technique, not very aggressive and reliable in these generally asymptomatic children.


p74. LAPAROSCOPIC ASSISTED ABDOMINAL - PERINEAL PULL THROUGH PROCEDURE FOR HIGH IMPERFORATED ANUS IN A BOY - SIX YEARS FOLLOW-UP.

J. Schleef M.D.*, A.K. Saxena M.D., K. Schaarschmidt M.D., G.H. Willital M.D.
Department of Ped. Surgery, Medical School, Graz Universiy Austria*, Clinic of pediatric Surgery, Münster university, Germany

Introduction: Imperforated anus is a challenging situation in ped. surgery. The aim is the construction of a neo anus and positioning the bowel in the midline of the pelvic muscle complex through the center of the sphincter muscle sling with minmal damage to nerves and muscles. We discribe a Pat. operated 1995 and the late follow-up results at the age of 7 yrs. Patient and Method: A boy (high imperated anus, sacral displasia, Down Syndr., heart failure) had a lap.- assisted abdominal-perineal pull-through (Rehbein´s technique) at the age of 14 m. after a prior colostomy. The colostomy was closed 3 mo.later. 4 trocars were used, the perineal procedure done over an inverse y-shape incision. Using the diaphanoscopic view from the perineum an ideal anal position could be found and the pull through passing through the mucosectomized rectal muscle tube was performed. Regular dilatations were performed for 3 mo. Results: The post op course was uneventful, discharge at day 7. At the age of 7 the cosmetic result is perfect, the anus well positioned. A manometry revealed a circular muscle complex with voluntary contractions. The child has regular bowel movements (1-2/d). No soiling. Conclusion:This experience in our first case shows excellent and very encouraging post op cosmetic, anatomic and functional results. It confirms the opinion of the authors and others that the minimal invasive approach should be regarded as an alternative to established procedures for imperated anus.


p75. EARLY EXPERIENCE WITH MINIMALLY INVASIVE SURGERY IN A PAEDIATRIC AND UROLOGIC SURGERY DEPARTMENT.

B.Tadini M.D .,L.Lonati M.D.,R.Gesmundo M.D., F.Canavese M.D,M.Bianchi M.D.
Paediatric Urology, Paediatric Surgery B Ospedale Infantile Regina Margherita - Torino

Aims: to evaluate indications and complications of laparoscopy in urologic and general surgery in children.

Methods: we reviewed our last 5 years experience. 167 procedures were performed. Patients age ranging from 2 months to 18 years. According to the procedure, patients were divided in 4 groups: Group1: 140 operative laparoscopies; Group2: 16 retroperitoneoscopic renal surgery; Group3: 1 thoracoscopy; Group4: 10 diagnostic laparoscopies. Major procedures in group 1, 2 and 3 were performed with an experienced laparoscopic surgeon.

Results: Group1: 80 appendicectomies (61 one-trocar;15 intraabdominal;4 mixed);23 cholecistectomy;22 bilateral varicocelectomy;8 biopsies;1 right adrenalectomy;1 Heller miotomy and fundoplicatio;1 intestinal adhesion resection, 1 lymphocele fenestration; 1 hysterovaginectomy and left gonadectomy; 1 first stage Fowler-Stephens.

Group2:15 nephroureterectomy; 1lower pole cyst marsupialization. Group3: 1 Esophagectomy. Group4: 7 non palpable testicles, 2 intersexs, 1 neoplastic staging. Two intraabdominal appendicectomies were converted to open surgery (1%).Twelve complications (7%) have been encountered: Group1: 5 trocar intraoperative site haemorrhage, 2 intraabdominal gallbladders ruptures, 2 umbilical infections; Group2: 3 peritoneal tearing.

Conclusions: laparoscopy is a feasible and safe procedure in an ever-increasing variety of procedures. An experienced laparoscopic surgeon is mandatory in complex cases and at the beginning of the learning curve.


p76. AN ADVANCED LAPAROSCOPIC REPAIR FOR LARGE GROIN HERNIA INTO THE SCROTUM OF INFANTS

Takehara H. , Ishibashi H., Ohshita M. and Tashiro S.
Department of Surgery, University of Tokushima, School of Medicine, Tokushima 770-8502, JAPAN

Laparoscopic percutaneous extraperitoneal closure (LPEC) had been reported as a new procedure for children with groin hernia at IPEG 1999 Congress. Although LPEC showed good results for usual cases of groin hernia, it seemed to be not enough to repair with LPEC for large groin hernia eviscerating into the scrotum. We present an advanced procedure with suturing the transverse abdominal fascial arch to the ileopubic tract laparoscopiccally adding LPEC. In order to reduce the large orifice of the internal inguinal ring with 3 ports (3mm) technique, an U-state suture was placed on from the fascial arch to the ileopubic tract avoiding the spermatic vessels and duct. An Endo-suture (19-gauge), that can be used to make a purse-string suture around the internal inguinal ring, was punctured on the midpoint of the inguinal line. The purse-string suture was placed on extraperitoneally around the internal inguinal ring. The Endo-suture was then removed from the abdomen together with these suture materials. The purse-string suture and the U-state suture were tied extracorporeally, respectively, and the internal ring was completely closed with double ligations. Of 150 cases treated with LPEC, 4 with large groin hernia have been added U-state suture. The advantages of this procedure are not only cosmetic, but also unnecessary dissection or reconstruction of the inguinal canal. Consequently, there is lower risk of injury to the spermatic duct or vessels than the conventional herniorrhaphy.


p78. LAPAROSCOPIC TREATMENT OF INTRAABDOMINAL AND RETROPERITONEAL LYMPHANGIOMAS

J. Waldschmidt, M.D., L.Meyer-Junghaenel, M.D., D. Cholewa, M.D.
Dept. of Pediatric Surgery, St. Joseph Hospital, Berlin, Germany

Introduction: Lymphangiomas are rare congenital vascular malformations. They cannot always be excised completely and are associated with high recurrence, complication and morbidity rates. Therefore an alternative concept of treatment is used since 1996.

Patients and Methods: Laparoscopic excision of the lymphangioma has been performed in 10 children using Nd:YAG laser 1064 nm. The bare fiber is introduced via puncture cannula or a special instrument, which allows angulation of flexible light conductor. Cyst wall is resected as much as possible, but avoiding the damage of adherent structures. The cyst ground was devitalised with non contact irradiation. With the fibertom mode, the temperature at the fiber tip is measured and adapted by optical feedback. This keeps the laser knife sharp at all times and ensures a more reliable laparoscopic excision.

Results: We excised 8 lymphangiomas complete and two subtotal. Operation time was 50-150 min. Hospital stay was 2-5 days. MRI control studies 3 month after the procedure showed small residual cysts after subtotal excision, which was treated by percutaneous ILT and in one case by relaparoscopy.

Conclusion: Minimal invasive laser treatment takes part in the treatment protocol of intraabdominal and retroperitoneal lymphatic vascular malformation.


p79. LAPAROSCOPIC TRANSPERITONEAL ADRENALECTOMY IN CHILDREN

Rene Wijnen MD, PhD; Marc Wijnen MD, Cees Noordam MD, Paul Rieu MD, Frans van der Staak MD, Rene Severijnen MD.
Departments Pediatric Surgery and Pediatrics, University Medical Centre St. Radboud, Nijmegen, The Netherlands.

Background: Benign adrenal pathology is rare in children. The authors report 2 cases of transperitoneal adrenalectomies.

The first patient is a 14 years old female, weight 80 kg, with a food-induced Cushing syndrom caused by an adrenal adenoma in the left adrenal gland of 2,5 x 2 cm. The second patient is a 12 years old female with an adrenogenital syndrom in which both adrenal glands needed to be removed.

In both cases a transperitoneal adrenalectomy in lateral position was performed. In the case of the both sided adrenalectomy, half-way the operation, the patient was changed on the other side. We used 4 trocars. The 10 mm telescope was introduced umbilical by the Hassan procedure. After mobilisation of the colon, the uper-pole region of the kidney is explored. After visualisation of the v. renalis, the vena surrenalis is located and ligated with clips, even as the artery. Then Adrenalectomy is performed and extracted in a bag.

Operative time was 150 minutes in case 1 and 250 minutes in case 2. Postoperative discharge after 3 days.

Transperitoneal adrenalectomy in the lateral position is maybe a preferable method above retroperitoneal adrenalectomy for surgeons who are more familiar with the intraperitoneal anatomy compared with the retroperitoneal anatomy. Compared with the open procedure, patients have less postoperative pain and discomfort and shorter hospital stay.


p80. LAPAROSCOPIC EXCISION OF CHOLEDOCHAL CYSTS WITH HEPATICOJEJUNOSTOMY IN INFANTS AND CHILDREN

Yeung CK, Lee KH, Sihoe J, Tam YH, Liu K,
Division of Paediatric Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong.

Objectives: We report our initial experience of using minimally invasive surgical techniques in the management of type I choledochal cysts.

Patienst & Methods: Three patients had undergone laparoscopic excision of choledochal cysts with hepaticojejunostomy. Patient 1: A 1- year old boy had a choledochal cyst first detected on antenatal screening. This progressively increased in size after birth from about 1 cm in diameter initially to 7.5cm at the time of surgery. Patient 2: A 17-year old girl presented with recurrent cholangitis and the size of the choledochal cyst at surgery was about 1cm in diameter. Patient 3: A 5-year old boy presented with recurrent abdominal pain secondary to an obstructing biliary stone lodged at the end of a 1.5 cm choledochal cyst, which required endoscopic retrieval. Surgical Techniques: The patient was in supine position with the surgeon either standing between the legs or on the right side. A 5mm 30o laparoscope was introduced via a 5mm port. Three more 3-5mm ports were inserted at right lower quadrant, right upper quadrant and left upper quadrant and another 5 mm port was inserted at right subcostal margin for the insertion of a liver retractor. The cyst was mobilised from the portal vein and hepatic artery to above the level of portal vein bifurcation at the porta hepatis, and from the pancreas distally. A 40cm Roux loop was fashioned extracorporeally via the enlarged umbilical port site and then re-routed back into the abdominal cavity and brought to the hilum in a retrocolic manner. End-to-side hepatico-jejunostomy was fashioned with interrupted 5 zero polydioxanone sutures with extracorporeal knot-tying techniques.

Results: Post-operative recovery of the 1-year old boy was complicated by a small infected collection at the hilum at 1 week after surgery. This settled on percutaneous drainage and antibiotic treatment. The girl and the 5-year old boy recovered uneventfully from surgery. On recent follow-up, all patients had remained asymptomatic and well.

Conclusions: Laparoscopic excision of choledochal cysts with re-constitution of bilio-enteric continuity can be safely and effectively performed in infants and young children. The long-term results using this minimal access approach will need to be further evaluated.


p81. ANGIOCATHETER AS PERCUTANEOUS PROBE TO ASSIST TRANSINGUINAL LAPAROSCOPIC EXAMINATION DURING HERNIA SURGERY IN CHILDREN

P.K.F. Yip , P.K.H. Tam* , M.K.W.Li,
Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong, * Division of Paediatric Surgery, Departemnt of Surgery, Queen Mary Hospital, Hong Kong

BACKGROUND: Transinguinal laparoscopy during herniotomy in children has been widely accepted to avoid unnecessary contralateral groin exploration. Different methods have been described to improve the accuracy of those indeterminate cases. We report an easy method making use of inexpensive material to improve the accuracy of the examination of those cases.

MATERIAL AND METHOD: During herniotomy the hernia sac was opened and transinguinal laparoscopy performed. In our last 50 cases of children aged 1 month to 14 year-old, a membranous fold was present over the contralateral ring in 5 of the cases and all other tests for contralateral hernia was negative. In those patients a 20 gauge angiocatheter was inserted percutaneously into contralateral lower abdominal cavity under laparoscopic guidance. The metallic stent of angiocatheter was receded and the Teflon sleeve acted as a ' probe ' to retract away any membranous structure and test the patency of processus vaginalis.

This percutaneous probing method helped to identify a hernia in two of the cases. No complication was resulted.

CONCLUSION: Percutaneous probing using angiocatheter is safe, easy and does not require any additional expensive instrument and it is a useful tool to assist transinguinal laparoscopy in indeterminate cases.


p82. LAPAROSCOPIC ROUX-EN-Y PORTOENTEROSTOMY FOR BILIARY ATRESIA

Edward Esteves, MD; Miguel Ottaiano, MD; Eriberto Neto, MD; José Devanir Jr, MD; Ruy E Pereira, MD
Pediatric Surgery Division, Goias Federal University, Goiania (GO), Brazil

Conventional surgery for extrahepatic bile duct atresia (EHBDA) usually requires a large laparotomy, with possible complications which may harm postoperative evolution and liver transplantation. Although laparoscopy has been used for diagnosis in EHBDA, the advantages of the minimally invasive access and the excellent visibility may favor laparoscopic surgical treatment. The authors present the first 4 cases of successful videolaparoscopic portoenterostomy for EHBDA, showing a new approach for enteroanastomosis. Methods: Laparoscopic hilar dissection and portojejunostomy was accomplished in 4 infants with biliary atresia, mean age 2 months at surgery, using 4 trocars. The umbilical site was used for extracorporeal Y-en-Roux enteroenterostomy, using a laparoscopic stapler in 2 cases and hand-sewn suture in the others. Results: Mean operative time was 190 minutes and no operative complications were observed. All but one became anicteric, with a mean follow up of one year. Esthetics has been excellent. Cholangitis occurred in 2 infants, one presented an umbilical hernia, and only one has shown signs of hepatic failure, being considered for liver transplantation at the moment. Conclusion: Laparoscopic portoenterostomy for EHBDA can be done safely in infants, helped by extracorporeal transumbilical enteric anastomosis, with some advantages compared with open surgery. The role of laparoscopic portoenterostomy in facilitating liver transplantation is yet to be defined in future.


p83. LAPAROSCOPIC SPLENECTOMY IN THE MANAGEMENT OF CHRONIC IDIOPATHIC THROMBOCYTOPENIC PURPURA IN THE PEDIATRIC PATIENT

Hoover JD, Geissler G
Children's Memorial Hospital, Department of Pediatric Surgery, Chicago, Illinois

Objective: To assess the safety and efficacy of treating children with chronic idiopathic thrombocytopenic purpura (ITP) with laparoscopic splenectomy (LS). Material and Methods: A retrospective review of the medical records was performed of patients who underwent LS for ITP during the last five years. Results: Since 1997, 62 consecutive pediatric patients have undergone chronic LS for hematological disease at our institution. Sixteen (26%) were for chronic ITP and none required conversion to an open procedure. All were safely removed using a 4 port lateral approach and endocatch bag with manual morcilation. No intraperitoneal spillage occurred. Six patients had accessory spleens removed. The average operative time was 166 minutes. No patient required transfusion and the average estimated blood was 75cc. Fifteen patients (94%) were discharged home in less than 24 hours and one required a three day stay for postoperative nausea. This same patient was readmitted within 30 days of discharge and required percutaneous drainage of a sterile subphrenic fluid collection and subsequently recovered without problems. Thirteen patients (81%) are disease free at last follow-up and 3 patients have chronic ITP but have not required platelet transfusion since surgery. Subsequent liver-spleen scans have shown no evidence of residual splenic tissue. Conclusion: ITP is safely treated with LS in the pediatric patient and has similar success rates as open splenectomy. It appears to be effective in identifying and removing accessory splenic tissue. LS safely and effectively removes splenic tissue in the pediatric patient with chronic ITP. Accessory splenic tissue is accurately identified and morbidity is minimized.


p84. EARLY LAPAROSCOPIC SPLENECTOMY IN INFANTS WITH SICKLE CELL DISEASE APPEARS TO LOWER DISEASE-RELATED MORBIDITY

Harold N. Lovvorn, III, MD , Kurt P. Schropp, MD, Jason Wilcox, BS, Lina Ramos, BS, Gerald Presbury, MD, Winfred Wang, MD, and Thom E Lobe, MD,
Departments of Surgery and Hematology, University of Tennessee School of Medicine, Memphis, TN,

HYPOTHESIS: Laparoscopic splenectomy (LS) in infants with sickle cell disease (SCD) reduces disease-related morbidity, transfusions, and hospitalizations. METHODS: Records of children having LS from August 1, 1996 to August 1, 2001 were reviewed for perioperative complications, length of operating time (LOT), length of hospital stay (LOS), pre-splenectomy transfusions and hospitalizations, pain medication, and overwhelming post-splenectomy sepsis (OPSS). T-test was used for analysis. RESULTS: 27 children had LS for hematologic disease, 12 with SCD (6 of these as infants; mean age, 19 months). There were no complications in infants (n = 6), and only 3 minor in those over 2 years (n = 21). LOT was 99.7 +/- 11.6 min for infants, 193.3 +/- 24 min for those over 2 with SCD (p < 0.01), and 160.2 +/- 12.9 min for all children over 2 (p = 0.003). LOS was 1.6 +/- 0.3 days for infants, 3.7 +/- 0.9 days for those over 2 with SCD, and 2.4 +/- 0.3 days for all patients over 2. Transfusions before LS were less in infants, 1.2 +/- 0.5 total units, versus those over 2, 14 +/- 7 units. Hospitalizations were fewer in infants, 1.5 +/- 1.5 versus 5.9 +/- 3. Utilization of pain medication was not different. No case of OPSS occurred. CONCLUSIONS: LS in infants is technically feasible and safe, reduces LOT, LOS, transfusions, and hospitalizations, while not increasing the risk for OPSS. As a result, LS for infants with SCD may reduce disease-related morbidity and health-care costs.


p85. LAPAROSCOPIC SPLENECTOMY MADE EASY: THE USE OF THE PLASMAKINETIC TISSUE MANAGEMENT SYSTEM

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

Objective: To evaluate the PlasmaKinetic (PK) Tissue Management System [Gyrus Medical] in laparoscopic splenectomy. The aim was to determine whether the PlasmaKinetic cutting forceps could enable the whole mobilisation of the spleen without the need for a change of instruments.

Method: 3 children aged 9, 10 and 14 years with spherocytosis required splenectomy. The 9 yr old also had gallstones so required a concurrent cholecystectomy. All procedures were performed laparoscopically facilitated by the use of 5mm PK Cutting Forceps.

Results: In all cases the splenic mobilisation was achieved using the forceps to grasp, dissect, coagulate, and transect. There was no requirement to change instruments to cut, clip or dissect, thus shortening the operative time to less than 1 hour. The PK L-hook was used in the cholecystectomy to mobilise the gallbladder and divide the cystic artery although 5mm clips were used in division of the cystic duct.

Conclusion: The PK instrument surpasses all other currently available dissecting and tissue sealing instruments with its ability to coagulate and also to cut even the major splenic vessels. This significantly reduces the operative time.


p86. DIFFICULTIES WITH THE STARTING OF PEDIATRIC LAPAROSCOPY IN A SERVICE OF PEDIATRIC SURGERY

Martínez-Almoyna Rullán, C; Alvarez Muñoz, V,
Service of Pediatric Surgery, Hospital Central de Asturias, Oviedo (Spain)

Introduction: Budgeting difficulties, Hospital organisation, and problems related with training can slow down the starting of laparoscopy in a Service of Pediatric Surgery (PS)

Material and Procedures: From 07/1997 to 07/2001, in our Service of PS, 160 pediatric laparoscopies (PL) were performed (age range 24 h. -15 y.). All clinical cases and the detected problems are reviewed (PL material, training, pediatricians, surgical team, results)

Results: Great difficulties in the purchase of material for PL, a low resistance from the surgical team and pediatricians, and a difficult previous training in PL were experienced. The principal surgeon has remained the same in 150/160 PL. Assistants have mainly been 4 trainee doctors in PS (anyone is performing PL now). Mainly, our series includes 31 appendicitis, 28 chronic abdominal pain, 20 gastroesophageal reflux, 17 cryptorchidism and 15 gallbladder lithiasis. The duration of PL, Hospital stays and training has presented a gradual improvement. No mortality

Conclusions: 1) Our Service of PS have had a great series of obstacles in PL to be overcome at first (training, purchase of material, experience curve). 2) Is mandatory to increase the specialisation and practical training of those specialising in PS and other interested staff (official courses, with practices on animals and relevant theoretical content). 3) Expansion of the PL to other pathologies and the usefulness of the acute appendicitis as a source of PL training are emphasised.


p87. PITFALLS IN LAPAROSCOPIC DECAPSULATION FOR SPLENIC CYSTS: CASE REPORT AND REVIEW OF THE LITERATURE

Rachel Mott, M.D., Haroon I Patel, M.D.,
Boston Medical Center, Boston MA

Introduction: Splenic cysts occur infrequently. While total splenectomy should be avoided, there is no consensus as to the treatment modality that offers the best preservation of splenic function, lowest morbidity and lowest recurrence rate. We report a case of recurrent splenic cyst after laparoscopic decapsulation, and identify potential pitfalls in the application of this technique.

Case Report: A 12-year-old male presented 2 months after a laparoscopic decapsulation of a large splenic cyst at another institution. A CT scan confirmed reaccumulation to its original size. The initial operative report described a partial deroofing of the cyst near the hilum, with placement of omentum in the defect. Repeat laparoscopy was performed, showing extensive adhesions to the liver and diaphragm, with approximately 50% of the spleen replaced by the cyst. An open partial splenectomy with a TA -90 stapler was performed. There were no complications and no recurrence at 18 months.

Conclusion: Laparoscopic decapsulation for splenic cysts has been safely and successfully performed. Large multiloculated splenic cysts that occupy more than half the spleen however, are potential pitfalls to adequate management by this technique. Omental packing of the defect impairs drainage and should be avoided. Splenic cystectomy, especially for true epithelial cysts, is preferable to partial decapsulation, which has a higher recurrence rate.


p88. LONG TERM EVALUATION OF CHILDREN WITH HEMATOLOGIC DISORDERS AFTER LAPAROSCOPIC SPLENECTOMY IN OUR INTITIAL EXPERIENCE DURING 1995-1996

Amulya K. Saxena, M.D., Jurgen Schleef, M.D., Klaus Schaarschmidt, M.D., Gunter H. Willital, M.D.,
PEDIARTIC AND NEONATAL SURGICAL CLINIC, WESTFALISCHE WILHELMS UNIVERSITY, MUNSTER, GERMANY

BACKGROUND: Laparoscopic splenectomy is presently accepted as the intervention of choice to treat children affected by hematologic diseases. Although various techniques have been described, the learning curve period has been found to be challenging. We analyze the experience and long term results of our first 10 laparoscopic splenectomies.

METHODS: From 1995 to 1996, 10 children underwent laparoscopic splenectomy with ages ranging between 4 and 14 years. In all the patients the spleen was captured and inserted into an extraction bag, fragmented, and then removed through the umbilical orifice.

RESULTS: Since the refinement of pediatric laparoscopic instruments was ongoing during our series reported and taking into account our learning curve, the mean operating time was 170 minutes (range 120 to 240 minutes). In the evaluation of the patients after 5 years, ultrasound examination along with scintigraphy studies were successful in ruling out the presence of splenosis in these patients. Also wound related as well as hematologic parameters were found to be within acceptable limits and have been presented.

CONCLUSIONS: Despite the technical difficulties, the patients had a shorter hospital stay, lower requirement of analgesics as well as extremely low gastrointestinal morbidity. Late evaluation of the patients from our initial series, after a period of 5 years, have shown no increase in morbidity in these patients operated as we gained our experience.


P89. LUNG SEQUESTER/CYST-LUNG ADENOMATOSIS: THORACOSCOPY VS MINI-THORACOTOMY VIDEO-ASSISTED

Francisco Berchi MD ; Juan Bregante MD; Juan Antón-Pacheco MD; Jaume Mulet MD; Jesus Cuadros MD; Araceli Garcia MD;
Department of Pediatric Surgery Hospital 12 de Octubre University Complutense Madrid/Spain

1st Case: We present the case of a 15 month old male child with a double extra left lung lobe sequester.The sequester, which had an independant supply direct from the aorta with venous drainage into the portal vein,was diagnosed by TAC with contrast medium.The history of the child presented 3 times pneumonitis on the basis of the left lung.Extirpation of a small sequester(2X2cm)and a larger sequester (4X3cm)was performed using thoracoscopy after application and dissection of the aberrant vascular supply using clips.The child was discharged after 72 hours with an uneventful postoperative course.

2nd Case: A 17 month old male child who presented with a left lung lobe malformation was prenatally diagnosed to have a cystic adenomatosis.

The thoracic TAC with contrast medium confirmed the diagnosis without the presence of abnormal vascular supply.A video assisted mini-thoracotomy was employed to resect the bronchus of the inferior lobe using the Endo-GIA stapler.

The chest tubes placed during the procedure were removed after 24 h and 48 h and the child was discharged on the 5th day without any complication

The thoracoscopic approach presents the advantages of a reduction in postoperative pain,decrease in the period of hospital stay as well as a better

chance to avoiding thoracic and vertebral deformities that may occur due to the adhesions following large scale thoracotomies.


p90. ARGON BEAM COAGULATOR AND VIDEO-ASSISTED THORACIC SURGERY IN CHILDREN

Cheli Maurizio M.D., Alberti Daniele M.D.,Colusso Mara M.D.,Bertani Alessandro M.D. and Locatelli Giuseppe M.D.
Department of Pediatric Surgery Ospedali Riuniti Bergamo Italy

INTRODUCTION: From January 2000 and March 2001, 4 children (median age 6 years)affected by thoracic diseases were treated by Video-Assisted Thoracic Surgery (VATS) and Argon Beam Coagulator (ABC).All patients were successfully treated without recurrence, except one.

METHODS: 3 patients were refered for liver transplantation and they presented postoperatively a copius right chilothorax drained for respiratory symptoms.We observed persistency of pleural effusion for up to 2 weeks after tube thoracostomy. 1 young girl was referd for dyspnea do to right pneumothorax from ruptured pleural blebs treated by tube thoracostomy for several days without relieve of symptoms. All the patient underwent VATS. Subpleural blebs were resected and pleurodesis was performed by ABC. All the patients with chilothorax received extensive pleurodesis by ABC and in 1 patient the procedure was repeted for persistency of chilothorax. There were no mortality and no intraoperative complications. The median postoperative hospital stays was 9 days (range 6-30 days). The median follow-up is 10 month (range 8 month-1 year).

CONCLUSIONS: The minimal chest injury resulting from VATS makes this approach feasible. In the future VATS and ABC will give better results as the technique is refined. Although this is a small series with a limited follow-up we were delighted that the procedure was able to provide clinical improvement in our patients.


p91. ECHINOCOCCUS GRANULOSIS CYST OF THE LUNG : TREATMENT BY THORACOSCOPY

Fouad Ettayebi,M.D - M.Benhammou,M.D.,
Department of pediatric surgery Children hospital of RABAT-MOROCCO

The hydatidosis is, in our country, at the endemic state. The lung location is the most frequent in the childhood. Conservative treatment of this pathology is possible by thoracoscopy.

In this study 20 patients with hydatidosis cyst of the lung have benefited from the video surgery at the children's hospital of RABAT (MOROCCO) between September 1998 and September 2001.

Three ports are used : a 10mm port for the endoscope and two operatives ports.

The hydatid fluid is aspirated via percutaneous way under control of the view to reduce the tension within the cyst. Hypertonic saline solution (15%) is injected within the cyst cavity as a solecidal agent. The proligere membrane is isolated in a plastic bag and taken out from the 10mm trocard incision. A capsectomy is realized.

Bronchial fistulas are closed and the cyst cavity is padded. A drain is left into the pleural cavity. The average hospitalization duration is about three days.

There is no diet in our Seri and there is no recurrence with a follow up of 6 to 36 months .

Conclusion : Video surgery achieves satisfactory results in the treatment of the hydatidosis cyst of the lung in children.


p92. VIDEOSURGERY PLICATION OF THE DIAPHRAGM IN INFANT (ABOUT THREE CASES)

Fouad Ettayebi, MD - M.Benhammou;MD.
Department of pediatric surgery Children hospital of RABAT-MOROCCO

Infants with an elevated hemidiaphragm secondary to eventration or paralysis from birth trauma may have significant pulmonary compromise. Plication of the diaphragm has been considered a therapeutic adjunct to improve pulmonary function but often necessitates a thoracotomy or a laparotomy. This report describes a videosurgery technique of plication that avoids the morbidity of an open surgery. Two patients aged 6 and 18 months who had eventration of the left hemidiaphragm were treated by laparoscopy. One patient, 8months old, who had elevation of the right hemidiaphragm was treated by thoracoscopy.. The surgery was performed under general anesthesia using 3,5-mm trocars and a 4mm endoscop.

The laparoscopic procedure required three trocars and the thoracoscpic procedure required four trocars. The operative time ranged from 45 to 60 minutes. There were no operative complications.The hospitalization duration is about 3 days. The follow up is from 8 to 12 months

This report demonstrates that laparoscopic plication of the left hemidiaphragm is a safe and effective technique. A thoracoscopic approch of the right hemidiaphragm eventration give a better exposure of the diaphragm and avoids the morbidity of a thoracotomy.


p93. PEDIATRIC EMPYEMA- AN ALGORITHM FOR EARLY THORACOSCOPIC INTERVENTION

Jason Knudtson, MD and Harsh Grewal, MD*
Section of Pediatric Surgery, Temple University Children's Medical Center, Philadelphia, PA and Department of Surgery, University of Kansas School of Medicine, Wichita,KS.

INTRODUCTION- The management of pediatric empyema remains controversial. We contend that early thoracoscopic intervention results in shorter hospital stays, decreased morbidity and superior outcomes. We propose an algorithm using early image-guided thoracoscopy as an effective treatment of pediatric empyema. METHODS AND PROCEDURES- Consecutive pediatric empyemas treated from 11/1997 to 4/2001 using a prospective management algorithm were reviewed. Demographic data, days to diagnosis, days to surgery, length of stay, chest tube days, complications, and follow-up were recorded. RESULTS- Twenty-two children with 24 empyemas were treated using this algorithm. Their mean age was 49 months. Mean days to diagnosis was 11 and from diagnosis to surgery was three. Imaging included CXR in all, ultrasound in 15 (68%) and CT scan in 13 (59%). One thoracoscopy was converted to a mini-thoracotomy because of difficulty in ventilation. Chest tube removal averaged 3 days with an average

length of stay of 13 days. One patient with an immune-deficiency required a second thoracoscopy for recurrent empyema and one patient developed a contra-lateral empyema. There were no other complications or deaths. Follow-up in 19 of 22 children (86%) at 5 months revealed no recurrences or mortality. CONCLUSION- Our treatment algorithm, using early image-guided thoracoscopy, is a safe and effective means of managing pediatric empyema, while shortening hospital stay and avoiding the morbidity of thoracotomy.


p94. THE CHALLENGE OF THORACOSCOPIC OESOPHAGEAL ATRESIA REPAIR

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

Objective: Oesophageal atresia repair remains one of the challenges of minimally invasive surgery. Since the first successful repair by Lobe and Rothenberg in Berlin in 1999, a handful of cases have been prepared in the USA and a few in Europe and elsewhere. Our aim was to divide the distal tracheo-oesophageal fistula and achieve a primary repair of oesophageal atresia in patients using the thoracoscopic approach.

Method: We describe the approach and operative technique in two cases.

Results: The first patient was a 1.6 kg female. Unfortunately the anatomy proved unfavourable with a right sided aortic arch and vascular ring. Division of the azygos vein and distal tracheo-oesophageal fistula were successfully achieved however. The second case, a 2.25 kg female infant had favourable anatomy and the operation was successfully completed thoracoscopically. At five days post-operatively a contrast swallow showed a widely patent anastomosis with no leak. Feeding was commenced and she progressed well, being discharged home on the twelfth post-operative day.

Conclusion: The thoracoscopic approach to oesophageal atresia repair can be performed safely with a favourable outcome.


p95. SPOT -SINGLE PORT THORACOSCOPY- FOR TREATMENT OF EMPYEMA IN CHILDREN

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

OBJECTIVE: To report that thoracoscopic surgical debridement of pleural space in children with empyema can be performed through a unique port and using standard scopes and instruments.

METHODS: Patients: 10 children of 2 to 13 years treated consecutively in 2 years operated between 5 to 26 days from the beginning of symptoms. Indication: a) Initial diagnosis of empyema with multiple septa, or b) 72 hours after the placement of a chest tube with persistence of fever and pus collection in the pleural cavity.

Technique: A 11.5 mm thoracoport was inserted at the site where the thickest collection of empyema was observed. In cases previously drained, access was achieved using the same chest tube wound . Standard 3 or 5 mm scopes and instruments were introduced simultaneously through the same port and a complete pleural debridement was achieved. After conclusion, a 24 to 32 french Argyle chest tube was placed using the same unique wound in all cases.

RESULTS: SPOT empyema debridement was successfully achieved in all 10 cases. Mean operation time was 70 minutes (60 to 140 minutes). No intraoperative complications were observed. Mean hospital discharge after SPOT was of 4 days (3 to 7 days). In all cases cosmetic results were excellent.

CONCLUSIONS: SPOT is a safe and useful technique for treatment of empyema in children. Besides presenting similar results than conventional multi-port technique, this approach seems to be less expensive and cosmetically better.


p96. VIDEO-ASSISTED THORACIC SURGERY FOR CYSTIC ADENOMATOID MALFORMATION OF THE LUNG; REPORT OF TWO CASES

Takashi Nogami, MD, Makoto Yagi, MD, Keisuke Nose, MD, Katsuji Yamauchi, MD, Hideki Yoshida, MD, Hiroomi Okuyama, MD, Akio Kubota, MD, Harumasa Ohyanagi, MD
Department of Surgery II, Kinki University School of Medicine, Osaka-Sayama, Japan, Department of Pediatric Surgery, Osaka Medical Center for Maternal & Child Health*, Izumi, Japan

Introduction: We report two cases with congenital cystic adenomatoid malformation of the lung (CCAML), which underwent lung resection by VATS.

Case 1: A two years old boy. Antenatal diagnosis of the right lung cysts had been made at 30 weeks of the gestation. He was followed up for two years, because he showed no subjective symptoms. By computerized tomography, cysts were confirmed to be localized in S6 and S10 of the right lung. Segmentectomy of S6 and S10 was performed by VATS.

Case 2: A two years old girl. She had repeated pneumonia of right lower lobe. CT examination showed cystic lesions. Right lower lobectomy was performed by VATS, although the adhesions of the lobe to pleura were seen.

Both cases were uneventful postoperatively and discharged within a week. Histological examination of the resected tissue showed CCAML (Type I and II, each) in both cases.

Conclusion: The video-assisted approach is a feasible alternative to thoracotomy in the treatment of congenital lung cysts, even if the patient is an antenatally diagnosed case or an infected case.


p97. THORACOSCOPY IN CHILDREN WITH DIAPHRAGMENTIC PARALYSIS AND BOCHDALEK HERNIA

J.Waldschmidt,M.D., D. Cholewa,M.D., H. Giest,M.D.
St. Joseph Hospital, Dpt. of Pediatric Surgery, Berlin, Germany

Introduction: In newborns with congenital eventeration of the diaphragm the conventional repair of the lesion has to be done transabdominally after completion of the preoperative management. In elder infants it is possible to choose alternative techniques.

Operative procedure: Three point standard thoracoscopy in contra-lateral position is used. We produce an arteficial pneumothorax with a pressure of 8mm mercury after introducing the Veress cannula through the 4th ICR of the mid axillar line. The edges of the diaphragmatic defect are good visible and can be grasped by an endoscopical forceps. The plication and fixation at the thoracic wall with large interrupted sutures follows. In cases with paralysis of the diaphragm the procedure is the same.

Cases: Since 1997 five children underwent this procedure in our hospital. Three times with Bochdalek hernia, two times with diaphragmatic paralysis.

Results: All children are alive. In one case recurrence occurred, a second intervention was necessary. No other complication. Were seen late results in these five children are excellent.

Discussion: In infants with Bochdalek hernia and diaphragmatic paralysis the minimal invasive repair by thoracoscopy is a reliable and gentle operative technique. In agreement with Y.Suzuma et al (1997) and I. NIETO-ZERMENO (1998) the thoracoscopy has special advantages over laparoscopic procedure.

Keywords: thoracoscopy, diaphragmatic hernia


p98. THORACOSCOPIC LUNG BIOPSIES IN CHILDREN WITH THE ENDOLOOP

Rene Wijnen MD, PhD; Marc Wijnen MD, Bart-Jan Yntema MD, Paul Rieu MD, Frans van der Staak MD, Rene Severijnen MD.
Departments Pediatric Surgery and Pediatrics, University Medical Centre St. Radboud, Nijmegen, The Netherlands.

Background: For good diagnosis of parenchymal disease of the lung, often a lung biopsy is needed. However an open lung biopsy was often seen as too invasive. Now with the introduction of minimal invasive techniques, thoracoscopic lung biopsy was introduced in our centre. Methods: The procedure consisted of introduction of three 5 mm ports, insufflation with CO2 till a pressure of 4 was used to create a good view. Lung biopsy was taken after ligation of the lung tissue with 2 endoloops PDS 4.0. The first 7 cases are reviewed here.

Results: In the period april - september 2001 we performed 7 thoracoscopic lung biopsies, the age ranged from 1 till 11 years, the average operation time was 28 minutes, the postoperative stay in the hospital was 1 day. Only 1 patient had a pneumothorax postoperatieve and needed for 24 hours a thoraxdrain. Conclusion: Thoracoscopic lung biopsy with an endoloop and low pressure CO2 insufflation is an easy and save procedure. Especially when starting thoracoscopic surgery in children this procedure is recomendable.


p99. SYRINGOCELE: OUR EXPERIENCE IN CLINICAL APPROACH AND ENDOSCOPIC TREATMENT

Podestà E., Ferretti S., Scarsi P.L., Di Rovasenda E,
Division of Surgical Emergency, Giannina Gaslini Institute, Genova, Italy

We re-evaluated 64 cases of syringocele observed in the period 1986-2000, considering anamnestic, clinical and anatomical aspects: type of syringocele, age at diagnosis, symptoms and patients' age at onset, concomitant or secondary lesions of the urinary tract, treatment, and follow up.

We found 2 "simple" syringoceles, 23 "closed", 30 "open", 8 "ruptured". A severe obstruction was found in 8 cases, all "ruptured" (VUR in 11 out of 16 ureters, dilatation alone in other 3 cases). Ten patients had monolateral VUR of lesser degree.

Infections was found in 24 out of 30 open syringoceles, along with moderate signs of obstruction. Mictural problems were observed in 14 out of 23 closed syringoceles, and in 18 out of 30 "open" cases. Five cases "closed" were diagnosed at birth, 3 other cases had severe recurrences of post-mictural hematuria. Diagnosis was accidental in alla the other patients.

As for the age at onset, besides the 6 cases with neonatal diagnosis, those cases with infection-related symptoms were usually diagnosed in infancy, while the ones with mictural troubles were usually diagnosed later.

Treatment included:

  1. 9 cases of "ruptured" syringoceles with bilateral hydro-ureteronephorsis and VUR had a bilateral reinplantation, along with resection of the posterior and anterior fornices
  2. "closed" syringoceles underwent distal opening
  3. "open" syringoceles underwent resection of the anterior fornix in 25 cases
  4. "simple" syringoceles required no treatment

Follow up examination was made after 3, 6 and 12 months with voiding cystourethrography and urodynamics.

A complete recovery of normal cystographic and urodynamic parameters, along with progressive disappearing of subjective symptoms, was obtained in 90% of patients.

In conclusion, we should consider the syringoceles as a spectrum of lesions, ranging from a minimal form, of no interest to the surgeon, to severe forms which can greatly impair upper urinary tract and renal function, much alike the posterior urethral valves in this regard: in fact the clinical findings and long-term evaluation of ruptured syringoceles do not differ much from the ones we observe in severe urethral valves. In the middle of the spectrum one can observe several cases in which the mictural troubles (with or without infection) are prominent, such as urge incontinence or frequent voiding, less frequently dysuria: in our series syringoceles are found in approximately 30% of cases of males with mictural troubles with organic causes. We can't but stress the importance of inspecting the whole urethra during endoscopy for a broad spectrum of urological problems.


Previous Page Back


Legal & Copyright Notice