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:
- the foramen of Monro and the third ventricle
greater than 5 mm;
- no scarring of subarachnoid space below the third
ventricle;
- 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 subti