Felix Schier

Laparoscopic Transabdominal Pyeloplasty in Children is Feasible Irrespective of Age

PURPOSE We assessed the feasibility of laparoscopic transabdominal dismembered pyeloplasty in 46 infants and children with regard to patient age. MATERIALS AND METHODS A total of 46 consecutive infants and children (31 male and 15 female) underwent laparoscopic transabdominal dismembered pyeloplasty using a 3 to 4-trocar technique. All patients had confirmed unilateral deterioration of renal function on isotope renography. The 46 patients were divided into 3 age groups--1 to 12 months (group 1, 14 patients), 1 to 7 years (group 2, 15 patients) and 7 to 18 years (group 3, 17 patients). Followup included clinical and ultrasound assessment, and isotope renography at 3 months. RESULTS Laparoscopic pyeloplasty was feasible in 44 of 46 patients (96%). Mean operative time was 175 minutes (range 120 to 270). The operation was converted due to impracticality of stenting the PUJ in 1 patient, and due to bleeding in 1. Mean operative time in 44 successful laparoscopic procedures was not significantly different among the 3 age groups (171 minutes in group 1, 169 minutes in group 2 and 173 minutes in group 3). Two patients required operative intervention for PUJ leakage, and 1 underwent percutaneous nephrostomy with a further uneventful course. Mean followup was 29 months (range 3 to 86). A total of 44 patients (96%) were asymptomatic and had improved PUJ drainage on isotope renography. Two patients underwent redo pyeloplasty due to recurrent hydronephrosis at 1 month and 2 years. CONCLUSIONS Laparoscopic transabdominal dismembered pyeloplasty is effective and safe in infants and children. The feasibility is also excellent in patients younger than 1 year. The transabdominal approach revealed good exposition without a disadvantage for the patient.

Pectus excavatum: history, hypotheses and treatment options

Pectus excavatum and pectus carinatum represent the most frequent chest wall deformations. However, the pathogenesis is still poorly understood and research results remain inconsistent. To focus on the recent state of knowledge, we summarize and critically discuss the pathological concepts based on the history of these entities, beginning with the first description in the sixteenth century. Based on the early clinical descriptions, we review and discuss the different pathogenetic hypotheses. To open new perspectives for the potential pathomechanisms, the embryonic and foetal development of the ribs and the sternum is highlighted following the understanding that the origin of these deformities is given by the disruption in the maturation of the parasternal region. In the second, different therapeutical techniques are highlighted and based on the pathogenetic hypotheses and the embryological knowledge potential new biomaterial-based perspectives with interesting insights for tissue engineering-based treatment options are presented.

Laparoscopic Resection Of Congenital Choledochal Cyst, Choledochojejunostomy, and extraabdominal Roux-en-Y anastomosis

BackgroundThe feasibility of laparoscopic resection of choledochal cyst and hepaticojejunostomy in children is still unclear. This report presents the author’s experience with a first series of patients.MethodsData from 11 consecutive children (median age 17.5 months, SD 22, range 2 to 70) with choledochal cyst scheduled for laparoscopy were collected prospectively. There were nine type I and 2 type V cysts according to Todani’s classification. All except one patient had intermittent jaundice or recurrent pancreatitis. The laparoscopic technique included excision of the cyst. A Roux-en-Y anastomosis was constructed after exteriorization of the small bowel via the infraumbilical trocar incision. After repositioning of the bowel an end-to-side hepaticojejunostomy was carried out laparoscopically.ResultsThe procedures were carried out in nine children without intraoperative events and a median duration of 289 min (SD 62). In two patients, the operation was converted after 60 and 90 min due to a lack of overview at the dorsal margin with problems in separation of the portal vein. Oral food intake was started within 2 days and tolerated well in all except one patient, in whom biliar fluid from the drain led to laparoscopic reevaluation on day 1. A small leak was resutured and the patient was discharged on day 5. In one patient, recurrent cholangitis and a dilated Roux-en-Y loop led to correction of some kinking of the loop via laparotomy after 3 months. All other patients are well with bile-stained stools after a mean follow-up of 13 months.ConclusionsLaparoscopic resection of congenital choledochal cyst and choledochojejunostomy in children is feasible. We feel that there is a considerable learning curve with the technique. Future studies will have to prove the feasibility of laparoscopic Roux-en-Y bowel anastomosis without the need for bowel exteriorization.

Work-related upper limb musculoskeletal disorders in paediatric laparoscopic surgery. A multicenter survey

BACKGROUND Surgeons are at risk for developing work-related musculoskeletal symptoms (WMS). The present study aims to examine the physical factors and their association with WMS among pediatric laparoscopic surgeons. METHODS A questionnaire consisting of 21 questions was created and mailed to 25 pediatric laparoscopic surgeons (LG). 23/25 surgeons (92%) completed the survey. The questionnaire was analyzed and then split into 2 groups. Group 1 (LG1) included surgeons with greater laparoscopic experience, and group 2 (LG2) included surgeons with less important laparoscopic experience. In addition, we constructed and sent to the same surgeons a similar questionnaire focused on WMS after an open procedure (OG) with the aim to compare results of LG with OG. RESULTS The prevalence rate of WMS with shoulder symptoms was 78.2% in surgeons that performed laparoscopy for more than 10 years, with 60.8% also reporting other pain. In 66.6% this pain is evident only after a long-lasting procedure. Forty-four percent of these surgeons require painkillers at least twice a week. Fifty percent of these surgeons also suffer at home. Fifty-five and one half percent of surgeons indicate that this pain is related to their laparoscopic activity. Forty-three and a half percent think that laparoscopy is beneficial only for the patient but has a bad ergonomic effect for surgeons. Sixty-five and two-tenths percent think that robotic surgery can be helpful to improve ergonomics. Comparing the groups, WMS occur more frequently in LG (78.2%) than in OG (56.5%), but this difference was not statistically significant (χ(2)=0.05). In addition, WMS occur more frequently in LG1 (84.6%) than in LG2 (70%), but this difference was not statistically significant (χ(2)=0.05). CONCLUSIONS These results confirmed a strong association between WMS and the number of laparoscopic procedures performed. Skilled laparoscopic surgeons have more pain than less skilled laparoscopic surgeons. WMS in the same group of surgeons are more frequent after laparoscopy than after open procedures. The majority of surgeons refer to shoulder symptoms.

Laparoscopic inguinal hernia repair does not impair testicular perfusion.

BACKGROUND Laparoscopic inguinal hernia repair techniques close the internal ring with a suture. Concern has been raised whether or not the testicular vessels are compromised with this technique. This study was undertaken to evaluate pre- and postoperative testicular perfusion and to compare it with healthy controls. PATIENTS AND METHOD Sixty-five boys (aged 6 weeks to 11 years; median, 1.4 years) with unilateral (n = 52) or bilateral (n = 13) inguinal hernias were treated laparoscopically. Testicular perfusion was measured using a recently developed neuromonitoring device (O2C; LEA Medizintechnik GmbH, Giessen, Germany), which combines light spectroscopy and laser Doppler technique. An optical probe was placed on the surface of each scrotal pouch for measurements at 2 depths (2 and 8 mm). Measurements involved oxygen (O(2)) saturation at the venous end of capillaries, the amount of hemoglobin within microvessels, the blood flow within microcirculation, and the velocity of the blood in microcirculation. Measurements were conducted before and after anesthesia, before and after surgery, and 6 weeks later. Twenty-one healthy boys of similar ages served as controls. RESULTS Measurements at 2-mm depth were unreliable. At 8-mm depth, the oxygen saturation of hemoglobin was between 62% and 75% (hypoxia would be <10%). The relative blood flow was between 160 to 235 arbitrary units, better than in healthy awake controls. Values were solely influenced by the administered fraction of inspired oxygen. Relative hemoglobin volume of the testes and blood flow velocity remained unchanged after surgery. Values were also normal when measured during early and long-term follow-up. CONCLUSION Laparoscopic inguinal hernia repair using suture closure of the internal inguinal ring does not impair testicular perfusion.

Characteristics of laparoscopic inguinal hernia recurrences

PurposeThis is so far the largest series of recurrences after laparoscopic inguinal hernia repair.Methods Video documents of 1,071 laparoscopic inguinal hernia repairs were retrospectively studied with respect to the affected side, anatomical appearance, gender, history and time interval between operation and recurrence. Only indirect, clinically manifest hernias were included.ResultsRecurrences occurred in 32 children (3%), 26 boys and 6 girls, aged 62 days to 14 years (median 3). The right side was affected in 21 children, the left in 10 and a bilateral recurrence was noted in 1 child. A total of 25 recurrences occurred medially to the previous suture and 7 laterally. The knot became loose in three cases. An experienced surgeon had only half the recurrences of a less experienced surgeon. The median time interval between surgery and recurrence was 3.8 months. Children up to the age of 2 years had the highest risk of recurrence. The right/left incidence of recurrences roughly was in proportion to the statistical incidence of hernias.ConclusionsBoys had more recurrences than girls. Most recurrences occur medially. The more experienced the surgeon was, the fewer recurrences he had. The stitches at the medial aspect of the hernia, close to the vas, seem to be the most crucial ones.

Decline in Infantile Hypertrophic Pyloric Stenosis in Germany in 2000–2008

BACKGROUND AND OBJECTIVE: The incidence of infantile hypertrophic pyloric stenosis (IHPS) is highly variable over time and geographic regions. A decline in IHPS incidence was recently reported in Sweden, the United States, Denmark, and Scotland. In Sweden, the IHPS decline seemed to be concurrent with a declining incidence in sudden infant death syndrome (SIDS), which suggested a common cause; the latter was attributed to campaigns against the prone sleeping position. We investigated the time course of the IHPS incidence in all German federal states (N = 16) between 2000 and 2008. We examined correlations between the IHPS incidence and the SIDS incidence. METHODS: Data were extracted from the public report of health (Gesundheitsberichterstattung des Bundes). We collected the numbers of IHPS (International Classification of Diseases, 10th Revision [ICD-10], code 40.0), SIDS (ICD-10, R95), and live births (LB; male/female) in each federal state for 2000–2008. RESULTS: The IHPS incidence declined in Germany from 2000 (3.2086/1000 LB [range: 1.67–5.33]) to 2008 (2.0175/1000 LB [1.74–3.72]; P = .005). The recorded incidence was highly variable in different federal states and over time. The SIDS incidence also declined during the same time period (2000, median: 0.759/1000 LB [interquartile range: 0.54–1.029]; 2008, median: 0.416/1000 LB [interquartile range: 0.285–0.6485]; P = .0255). However, the SIDS regional distribution was different from that of IHPS. CONCLUSIONS: The IHPS incidence declined by ∼38% nationwide. A parallel decline in SIDS displayed a different pattern in regional distribution; thus, a common cause was unlikely. The regional differences indicated that etiologic factors remained unresolved.

Evaluation of severely displaced radial neck fractures in children treated with elastic stable intramedullary nailing.

Background We performed a retrospective case study of 28 consecutive severely displaced radial neck fractures (Judet types III and IV) in children treated with elastic stable intramedullary nailing using the Metaizeau technique. Methods We reviewed all preoperative radiographs and classified the injuries according to Judet. All patients were asked to return for later assessment. They underwent physical examination; radiographs were taken; and they were asked for subjective assessment. An evaluation of clinical results was performed using the Mayo Elbow Performance Score (MEPS). Results According to Judet classification there were 13 type III and 15 type IV fractures. Using the MEPS, excellent results were achieved in 23 cases (82%) and good results in 5 cases (18%). The average MEPS was 97 points. Five patients complained of mild pain. Three malunions were observed. Conclusions Elastic stable intramedullary nailing is a minimally invasive technique, allowing stable fixation and providing excellent to good outcomes with a low complication rate. Level of Evidence We performed a retrospective level 4 study of case series.

Thoracoscopy in children.

Pediatric surgical experience with video-assisted thoracoscopy is limited. The authors report their experience with 27 thoracoscopies in 22 children. The median age was 6.1 years (range, 1 day to 16 years). The two primary indications for thoracoscopy were management of pneumothorax and mediastinal cysts. Fifteen thoracoscopies accomplished their purpose without complications. Intraoperative complications required conversion to an open operation in three patients. One bronchogenic cyst and four pneumothoraces recurred. The main complications were poor visualization, bleeding from an intercostal artery, and difficulty with suturing. Compared with open thoracotomy, anesthesia time did not differ significantly, and less pain medication was required postoperatively.

Microlymphography of spontaneous lymph vessel anastomosis in small bowel transplantation in the rat

Following small bowel transplantation, new lymph vessel anastomoses form spontaneously. Surgical anastomoses of the lymphatic vessels are unnecessary. The formation occurs in three stages. To the second postoperative day, lymph stays within the lymphatic vessels of the transplant. Following the fourth postoperative day, lymph flows within preexistent adventitial lymphatic vessels along the transplanted mesenteric artery to the arterial anastomosis at the aorta and stops there. From the sixth postoperative day on, lymph crosses the arterial anastomosis for the first time and flows along the recipients aorta. To the eighth postoperative day a new lymph anastomosis is formed between the adventitia of the aorta and the neighbouring major lymphatic vessels. In the experiments presented here, these are represented by the vasa lymphatica testicularia sinistra of the recipient. Thus, the new anastomosis between lymphatic vessels is complete on the eight postoperative day. These new vessels gradually dilate with time.