François Becmeur

Pulmonary sequestrations: Prenatal ultrasound diagnosis, treatment, and outcome

BACKGROUND/PURPOSE With the development of antenatal diagnosis of pulmonary sequestrations, the authors decided to define more accurate perinatal operative indications. METHODS/RESULTS Antenatal ultrasound scanning (US) enabled the diagnosis of congenital pulmonary malformation in 10 cases between the twentieth and the thirty-third week of amenorrhea (WA; average, 26 WA). An absolute or relative regression of the thoracic mass size was observed in five patients. The systemic arterial blood supply was identified in four patients by Doppler US. Two fetuses required treatment. One of them suffered from a voluminous sequestration, larger than one hemithorax, with polyhydramnios. Three successive paracentesis of ascites and amniotic fluid allowed the pregnancy to continue until term. The second fetus had a sudden left hydrothorax at 30 WA and was treated by a pleuroamniotic shunt. Five spontaneous partial involutions of the mass during the antenatal period were observed. The 10 patients underwent surgery after birth. There was no mortality. Morbidity occurred in one case of antenatal treatment. Twenty-eight other cases of antenatal diagnosis of pulmonary sequestration have been described in the medical literature. Spontaneous involution of the mass has been reported in eight fetuses and its complete disappearance in two cases. Thirteen fetuses had polyhydramnios. Five of these progressed spontaneously without treatment; only two survived. Two other fetuses were drained or punctured, and one survived. Premature deliveries were undertaken for the six other fetus; there was one perinatal death. CONCLUSIONS Sequestrations with polyhydramnios may be treated in an early prenatal period. Mortality and morbidity rates are still high. At birth, large-sized sequestrations (more than half a hemithorax) must be operated on, even in cases of no respiratory distress. Medium-sized sequestrations must be operated on to remove the mass. Small and asymptomatic sequestrations must be operated on in case of intralobar forms (often cystic), or with a big blood supply. The artery may be responsible for severe complications (hemoptysis, aneurysm).

Thoracoscopic treatment for delayed presentation of congenital diaphragmatic hernia in the infant. A report of three cases.

Background: Delayed presentations of congenital hernia occurring outside of the neonatal period have been reported for all ages. Classically, repair of the hernia defect involves a transverse subcostal laparotomy in the pediatric age group and usually a thoracotomy in the adult. The first report describing a laparoscopic repair of a congenital diaphragmatic hernia in a 6-month-old infant was published in 1995. During the past 25 years, 17 patients with delayed presentation of congenital diaphragmatic hernias have been managed by our pediatric surgery team. The last three patients underwent surgery thoracoscopically. Patients and Methods: This study involved two boys (ages, 8.3 and 19 months, respectively) and one girl (age, 9 months) weighing 8 to 13 kg. All three infants underwent surgery using a thoracoscopic approach with general anesthesia. A thoracic epidural catheter was placed systematically for postoperative analgesia during the first 24 hours. Reduction of the hernia contents using one optical trocar and two operating trocars was difficult in the case without any hernia sac. In the cases with a hernia sac, reduction was easily and quickly obtained with a pleural insufflation of carbon dioxide (~8 mmHg). The hernia defect was repaired using interrupted sutures of 2/0 Ethibond. For two of the three patients, this repair was reinforced with staples in the one case and a nonresorbable mesh in the other case. Results: The mean operative time was 78 min. The chest tube was removed on the first or second postoperative day and the patients were discharged on the fourth or fifth postoperative day. At the 19-month follow-up assessment in one case, the chest x-ray was perfectly normal and diaphragmatic motion also was confirmed to be normal by ultrasonography. Conclusions: The thoracoscopic approach for the repair of delayed-presentation congenital diaphragmatic hernia is feasible. Our results demonstrate the safety and efficiency of this surgery, as well as a remarkable functional and cosmetic result and a very quick recovery.>

A continuous series of 96 laparoscopic inguinal hernia repairs in children by a new technique

BackgroundThe aim of this study was evaluate a novel technique of laparoscopic hernia repair in children.MethodsEighty two consecutive patients aged ≥2 years old were operated on for hernia repair using a laparoscopic technique that reproduced every step of the conventional open procedure. Technical details and clinical results are reported.ResultsNinety six sacs were divided in 82 patients (15 girls and 67 boys). Fourteen bilateral hernias that had been diagnosed before operation in nine cases and during laparoscopy in five cases were repaired. Nine controplateral dimples were left and not repaired. Mean operative time was 23 min in girls and 28 min in boys for unilateral hernias, and 30 min in girls and 40 min in boys for bilateral hernias. Sixty-seven of the children were followed up 6 months later. None of them suffered recurrences. No unsightly scars were observed at the port sites. Discomfort did not extend beyond 48 h after the operation, enabling a rapid return to normal activities.ConclusionDividing the sac and suturing the peritoneum is feasible and efficient by laparoscopy. Compared with the other techniques that have previously been reported, either without any dissection of the sac or any ligature, our technique seems to be advantageous. It is not time consuming and does not require any special laparoscopic skill.

Laparoscopic versus open appendectomy in children : A retrospective comparative study of 2,332 cases

AimThe laparoscopic treatment of paediatric appendicitis remains controversial, especially in the presence of complications. This study evaluated the outcomes of open appendectomy (OA) and laparoscopic appendectomy (LA) by analysing the data from a multicentre study.MethodsThe authors retrospectively reviewed a series of 2,332 appendectomies (1,506 LA and 826 OA) performed in children and adolescents (median age 8 years) in 9 different centres of paediatric surgery. For the patients operated using laparoscopy, an IN procedure was employed in 921 (61.2%), an OUT procedure in 571 (37.9%) and a MIXED procedure in 14 (0.9%). In the open surgery, a McBurney incision was adopted in 795 patients (96.4%).ResultsMedian duration of surgery was 40 minutes for LA and 45 minutes for OA. Median hospital stay was 3 days (LA) and 4.3 days (OA) in case of simple appendicitis and 5.2 days (LA) and 8.3 days (OA) in case of peritonitis. Complications were recorded in 124 LA cases (8.2%) and 65 OA cases (7.9%). The conversion rate in laparoscopy was only 1.6% (25 cases). The statistical analysis was performed using the Mann–Whitney test, and the main significant difference that emerged was the length of hospital stay, which was in favour of laparoscopy compared with open surgery (P < 0.0001).ConclusionsWe conclude that in clinical settings where laparoscopic surgical expertise and equipment are available and affordable, LA seems to be an effective and safe alternative to OA. Three out 9 centres participating in our survey perform LA in all patients with a suspicion of appendicitis. Our study shows that laparoscopy significantly reduces hospital stay in case of appendicitis and peritonitis and presents an extremely low conversion rate (1.6%) to open surgery. Laparoscopic transumbilical appendectomy (37.9%) in our series seems to be a simple option, even for less-skilled laparoscopic surgeons.

Laparoscopic Partial Splenectomy: Indications and results of a multicenter retrospective study

IntroductionPartial splenectomy (PS) in children is a surgical option in haematological diseases and focal splenic tumours. The aim of this study was to describe the feasibility and the results of laparoscopic partial splenectomy in children in these two indications by a multicentric retrospective study.MethodsThe authors reviewed the files of all children who underwent laparoscopic PS between March 2002 and September 2006 in two paediatric surgical centers. The data of 11 children were collected and included clinical presentation, age, gender, radiographic examinations, surgical procedure, need for blood transfusion and early complications.ResultsFrom March 2002 to September 2006, laparoscopic PS had been performed on 11 children (6 boys, 5 girls) aged 23 months to 11 years (mean 7, 9). Four children had splenic focal tumours and seven had haematological diseases: six hereditary spherocytosis (HS) and one hemoglobinosis E. During the surgical procedure for haematological diseases 75–80% of the splenic tissue was removed. When PS was performed for focal splenic tumours, the splenic remnant was around 70%. No preoperative complications occurred (no bleeding, no diaphragmatic injury). Neither preoperative nor conversion was necessary. One postoperative complication occurred (left pleural effusion) but required no further treatment. The mean hospital stay was 7.7 days (range from 3 days to 10 days). No infectious postoperative complications occurred; the mean follow up was 21.1 months (range 3–52 months).ConclusionLaparoscopic partial splenectomy is feasible and safe in children with hypersplenism or focal splenic tumours. Partial splenectomy is a good way to prevent postsplenectomy infections by preservation of the immune role of spleen in children with haematological diseases. This technique performed for focal splenic tumours allows the surgeon to choose the size of the splenic remnant.

Tracheobronchial ruptures from blunt thoracic trauma in children

BACKGROUND/PURPOSE Tracheobronchial ruptures in blunt thoracic trauma in children are rare. The aim of this study was to suggest the means of an early diagnosis and a conservative management as often as possible. METHODS Sixteen cases of tracheobronchial ruptures by blunt thoracic trauma were observed over 26 years in 9 regional pediatric centers. RESULTS There were 12 boys and 4 girls, from ages 1 hour to 17 years. Nine children presented with associated lesions. Fibroscopy established the following diagnosis: 8 tracheal wounds and 8 bronchial wounds. Six children were operated on within 18 hours (on average) after installation of a thoracic drainage. Two lobectomies, 3 ideal tracheal sutures, and 1 bronchial suture were performed. Seven children were treated exclusively by thoracic drainage. Two of them were intubated through the lesion, leading to a transitory endoprothesis accompanied or not by an external thoracic drainage. One infant recovered spontaneously. There were no deaths in this series. Two recurrent postoperative nerve injuries were noted, one of which was a transitory spontaneously resolutive scar bud and one a granuloma treated by laser. Three times, a stenosis occurred after a conservative management. Two were operated on. CONCLUSIONS Tracheobronchial ruptures in children are rare. An early fibroscopy holds an important place in the approach of this pathology. Treatment is variable, based on thoracic lesions, their tolerance by the child, and associated lesions. Surgery is not the only therapy because conservative treatment by simple thoracic drainage or lesion intubation has proved effective.

Multicentric assessment of the safety of neonatal videosurgery

BackgroundComplex procedures for managing congenital abnormalities are reported to be feasible. However, neonatal videosurgery involves very specific physiologic constraints. This study evaluated the safety and complication rate of videosurgery during the first month of life and sought to determine both the risk factors of perioperative complications and the most recent trends in practice.MethodsFrom 1993 to 2005, 218 neonates (mean age, 16 days; weight, 3,386 g) from seven European university hospitals were enrolled in a retrospective study. The surgical indications for laparoscopy (n = 204) and thoracoscopy (n = 14) were congenital abnormalities or exploratory procedures.ResultsOf the 16 surgical incidents that occurred (7.5%), mainly before 2001, 11 were minor (parietal hematoma, eventration). Three neonates had repeat surgery for incomplete treatment of pyloric stenosis. In two cases, the incidents were more threatening (duodenal wound, diaphragmatic artery injury), but without further consequences. No mortality is reported. The 26 anesthetic incidents (12%) that occurred during insufflation included desaturation (<80% despite 100% oxygen ventilation) (n = 8), transient hypotension requiring vascular expansion (n = 7), hypercapnia (>45 mmHg) (n = 5), hypothermia (<34.9°C) (n = 4), and metabolic acidosis (n = 2). The insufflation had to be stopped in 7% of the cases (transiently in 9 cases, definitively in 6 cases). The significant risk factors for an incident (p < 0.05) were young age of the patient, low body temperature, thoracic insufflation, high pressure and flow of insufflation, and length of surgery.ConclusionDespite advances in miniaturizing of instruments and growth in surgeons’ experience, the morbidity of neonatal videosurgery is not negligible. A profile of the patient at risk for an insufflation-related incident emerged from this study and may help in the selection of neonates who will benefit most from these techniques in conditions of maximal safety.

Laparoscopic resection of abdominal neuroblastoma.

BackgroundSince indications for laparoscopic adrenalectomy have progressively expanded to pediatric surgery, preliminary reports have studied the laparoscopic approach for abdominal neuroblastoma (NB). We aimed to report on the indications and the results of laparoscopic resection in a large series of abdominal NBs.MethodsA retrospective multicenter study included 45 children with abdominal NBs (28 localized, 11 stage 4, 6 stage 4s) and laparoscopic resection of their abdominal primary tumor. Primary site of the tumor was the adrenal gland in 41 cases and retroperitoneal space in 4. The median age at surgery was 12 months (1–122); median tumor size was 37 mm (12–70). Resection was performed through transperitoneal laparoscopy (n = 38) or retroperitoneoscopy (n = 7).ResultsComplete macroscopic resection was achieved in 43 of 45 children (96%). The median duration of pneumoperitoneum was 70 min (30–160), and the length of hospital stay was 3 days (2–9). Four procedures (9%) were converted to open surgery, and tumor rupture occurred in three cases. Of the 28 children with localized disease, there was a 96% overall survival (OS) rate after a median follow-up of 28 months (4–94). There was one local relapse in this subgroup, with subsequent complete remission. For the entire 45-children cohort, four children died and three presented a recurrence resulting in OS, disease-free survival, and event-free survival rates of 84% ± 8.1, 84% ± 8.2, and 77% ± 9.1 respectively.ConclusionLaparoscopic resection of abdominal primary allows effective local control of the disease in a wide range of clinical situations of neuroblastoma, with an acceptable morbidity.

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.

Wandering spleen in children: multicenter retrospective study

Wandering spleen in children is a rare condition. The diagnosis is difficult, and any delay can cause splenic ischemia. An epidemiologic, semiological, and surgical diagnosis questionnaire on incidence of wandering spleen in children was sent to several French surgical teams. We report the results of this multicenter retrospective study. Fourteen cases (6 girls, 8 boys) were reported between 1984 and 2009; the age range varies between 1-day-old and 15 years; 86% were seen in the emergency department. Ninety-three percent had diffuse abdominal pain. For 57% of the cases, it was their first symptomatic episode of this type. No diagnosis was established based on the clinical results alone. All patients had presurgical imaging diagnosis. Open surgery was performed on 64% cases. Forty-three had splenectomy for splenic ischemia. Thirty-six percent had splenopexy, 14% had laparoscopic gastropexy, and 7% had spleen repositioning and regeneration. Complications were noted in 60% of the cases resulting in postsplenopexy splenic ischemia. Early diagnosis and surgery are the best guarantee for spleen preservation. Even if the choice of one technique, splenopexy or gastropexy, can be argued, gastropexy has the advantage of avoiding splenic manipulation and restoring proper physiologic anatomy. When there is no history of abdominal surgery, laparoscopy surgery seems the best procedure.