Francesco Turrà

Current concepts in the management of inguinal hernia and hydrocele in pediatric patients in laparoscopic era

The surgical repair of inguinal hernia and hydrocele is one of the most common operations performed in pediatric surgery practice. This article reviews current concepts in the management of inguinal hernia and hydrocele based on the recent literature and the authors׳ experience. We describe the principles of clinical assessment and anesthetic management of children undergoing repair of inguinal hernia, underlining the differences between an inguinal approach and minimally invasive surgery (MIS). Other points discussed include the current management of particular aspects of these pathologies such as bilateral hernias; contralateral patency of the peritoneal processus vaginalis; hernias in premature infants; direct, femoral, and other rare hernias; and the management of incarcerated or recurrent hernias. In addition, the authors discuss the role of laparoscopy in the surgical treatment of an inguinal hernia and hydrocele, emphasizing that the current use of MIS in pediatric patients has completely changed the management of pediatric inguinal hernias.

Evaluation and outcome of the distal ureteral stump after nephro-ureterectomy in children. A comparison between laparoscopy and retroperitoneoscopy

BACKGROUND In children with a poorly functioning kidney due to vesicoureteral reflux (VUR) or ureteropelvic junction obstruction, management is by nephrectomy with total or proximal ureterectomy. The complete removal of all the ureter minimizes the risk of future morbidity associated with the distal ureteral stump (DUS), including febrile urinary tract infections (UTIs), lower quadrant pain and hematuria, the so-called ureteral stump syndrome. OBJECTIVE To assess the outcome of the DUS after nephroureterectomy, we analyzed our recent experience of nephrectomy performed via retroperitoneoscopy and via laparoscopy. METHODS The records of 21 consecutive patients (median age 3.5 years, range 1-10 years) who underwent nephroureterectomy via laparoscopy or via retroperitoneoscopy were retrospectively reviewed for symptoms caused by DUS and their management. Nephrectomy was undertaken for a poorly functioning dysplastic (4), scarred from VUR (10) or hydronephrotic (7) kidney. In the laparoscopic group (11 pts), 6 cases required nephrectomy for reflux while 5 patients were operated for hydronephrotic or dysplastic non-functioning kidney. In the retroperitoneoscopic group (10 pts), nephrectomy was performed for reflux in 4 cases versus 6 patients affected by hydronephrotic or dysplastic non-functioning kidney. The patients were evaluated using ultrasound (US) to check DUS length and clinically to evaluate symptoms due to a symptomatic DUS. RESULTS The average length of surgery was 50 min for laparoscopy and 80 min for retroperitoneoscopy. The average of follow-up was 5 years. The length of DUS after laparoscopic nephrectomy was shorter (range 3-7 mm, statistically significant) than the DUS after retroperitoneoscopy (range 2-5 cm) (p < 0.001). Laparoscopic patients were all asymptomatic. Two patients, after retroperitoneoscopic nephrectomy, presented with recurrent UTIs; a voiding cystography revealed a VUR on the residual DUS and a redo surgery was performed in both the patients to remove the DUS (Figure). DISCUSSION Several authors have stated that, in case of subtotal ureterectomy, the incidence of symptomatic DUS after nephrectomy for high-grade vesicoureteric reflux is low. However, in our series, the incidence of symptomatic DUS after nephroureterectomy was not insignificant (2/21, 9.5%). Symptoms related to a refluxing DUS occurred only in patients undergoing retroperitoneoscopic nephroureterectomy, where the DUS was longer than the DUS detected in laparoscopic patients. CONCLUSIONS Considering that laparoscopy permits removal of all the ureter near the bladder dome, in children with non-functioning kidney due to VUR, it is advisable to always perform a laparoscopic rather than a retroperitoneoscopic nephrectomy to prevent problems related to a symptomatic DUS.

Management of gastroesophageal reflux disease in pediatric patients: a literature review

Gastroesophageal reflux (GER), defined as the passage of gastric contents into the esophagus, is a physiologic process that occurs throughout the day in healthy infants and children. Gastroesophageal reflux disease (GERD) occurs when gastric contents flow back into the esophagus and produce symptoms. The most common esophageal symptoms are vomiting and regurgitation. Lifestyle changes are the first-line therapy in both GER and GERD; medications are explicitly indicated only for patients with GERD. Surgical therapies are reserved for children with intractable symptoms or who are at risk for life-threatening complications of GERD. The laparoscopic Nissen antireflux procedure is the gold standard for the treatment of this pathology. A literature search on PubMed and Cochrane Database was conducted with regard to the management of GERD in children to provide a view of state-of-the-art treatment of GERD in pediatrics.