G. Ascione

Splenectomy in childhood : The laparoscopic approach

AbstractBackground: We set out to analyze the results of the first 19 laparoscopic splenectomies performed by our team in order to show the advantages and limitations of the laparoscopic approach to this kind of procedure in children. Methods: Between March 1994 and June 1997, 19 children underwent laparoscopic splenectomy; two of them also had a concomitant cholecystectomy. Their ages ranged between 4 and 14 years (median, 7.2 years). There were 14 girls and 5 boys. All the patients underwent elective laparoscopic splenectomy: seven children had hereditary spherocytosis, six were affected by a β thalassemia, five had an idiopathic thrombocytopenia purpura, and one presented with sickle cell disease. Results: Mean operating time was 145 min (range, 110–240 min). Hospital stay ranged from 2 to 5 days (median, 3 days). In three patients, the spleen was removed with a 7-cm mini-laparotomy, according to the technique of Pfannenstiell, in the suprapubic region. In the other 16 cases, the spleen was captured into a extraction bag, finger-fragmented, and removed from the umbilical orifice. Conclusions: Laparoscopic splenectomy can be performed only when the spleen can be removed through the umbilical orifice with an extraction bag. For this reason, preoperative ultrasonography is necessary to measure the exact spleen volume. When the spleen is very large, an open splenectomy is preferable.

One-trocar laparoscopy

Background: The aim of this paper is to show the efficacy of laparoscopy using only one umbilical trocar to treat abdominal complications of hydrocephalic children with ventriculoperitoneal shunts (VPS). Materials and Methods: In a 15-year period, 14 laparoscopies were performed on as many children with VPS complications: in the last 4 patients only one trocar was used to solve the complications, and this subgroup will be the object of the present study. Concerning the indication for surgery, the patients presented one catheter lost in the abdominal cavity; one cerebrospinal fluid pseudocysts; one bowel obstruction; and one malfunctioning peritoneal limbs of the catheter. We used the one-trocar laparoscopic approach in all the 4 patients, and the 10-mm trocar was always introduced through the umbilical orifice in open laparoscopy. Results: The laparoscopic technique was curative in all four cases and permitted the solution of the complication. Conclusions: One-trocar laparoscopic surgery can be considered as the ideal procedure in case of abdominal complications of VPS in children with hydrocephalus.

Laparoscopic-assisted jejunostomy : An effective procedure for the treatment of neurologically impaired children with feeding problems and gastroesophageal reflux

BackgroundFeeding difficulties and gastroesophageal reflux (GER) are major problems in severely neurologically impaired children. Many patients are managed with a simple gastrostomy, with or without fundoplication. Unfortunately, fundoplication and gastrostomy are not devoid of complications, indicating the need for other options in the management of these patients.MethodsSince January 2002, seven patients (age range, 5-14 years) have been treated by creating a jejunostomy with the laparoscopic-assisted procedure. The procedure was performed using two 10-mm trocars. The technique consists of identifying the first jeujnal loop, grasping it 20-30 cm away from the Treitz ligament with fenestrated atraumatic forceps, and exteriorizing it to the trocar orifice under visual guide. The jejunostomy was created outside the abdominal cavity during open surgery. At the end of the jejunostomy, the correct positions of the intestinal loop and feeding tube were evaluated via laparoscopy.ResultsSurgery lasted 40 min on average, the laparoscopic portion only 5 min. There were no perioperative complications; hospital stay was 3 or 4 days for all patients. At the longest follow-up (18 months), all patients had experienced a significant weight gain, with a high level of parental satisfaction. One patient died 1 year after the procedure of unknown causes. All the others are well, without complications or problems, and their parents are extremely satisfied with the improved quality of life of their children.ConclusionsLaparoscopic-assisted jejunostomy is a safe and effective procedure to adopt in neurologically impaired children with feeding problems and GER. This procedure solves these patients’ feeding problems even if the reflux is not completely eliminated. We advocate the use of this procedure in neurologically impaired patients with feeding problems and reflux due to its overall practicability and because there is minimal surgical trauma. This technique is extremely safe because the surgeon is able to verify, at the end of procedure, the status of the jejunostomy from outside and inside the abdominal cavity. The improvement in the quality of life of these children after the jejunostomy seems to be the major advantage of this procedure.

Laparoscopic-assisted jejunostomy

BackgroundFeeding difficulties and gastroesophageal reflux (GER) are major problems in severely neurologically impaired children. Many patients are managed with a simple gastrostomy, with or without fundoplication. Unfortunately, fundoplication and gastrostomy are not devoid of complications, indicating the need for other options in the management of these patients.MethodsSince January 2002, seven patients (age range, 5-14 years) have been treated by creating a jejunostomy with the laparoscopic-assisted procedure. The procedure was performed using two 10-mm trocars. The technique consists of identifying the first jeujnal loop, grasping it 20-30 cm away from the Treitz ligament with fenestrated atraumatic forceps, and exteriorizing it to the trocar orifice under visual guide. The jejunostomy was created outside the abdominal cavity during open surgery. At the end of the jejunostomy, the correct positions of the intestinal loop and feeding tube were evaluated via laparoscopy.ResultsSurgery lasted 40 min on average, the laparoscopic portion only 5 min. There were no perioperative complications; hospital stay was 3 or 4 days for all patients. At the longest follow-up (18 months), all patients had experienced a significant weight gain, with a high level of parental satisfaction. One patient died 1 year after the procedure of unknown causes. All the others are well, without complications or problems, and their parents are extremely satisfied with the improved quality of life of their children.ConclusionsLaparoscopic-assisted jejunostomy is a safe and effective procedure to adopt in neurologically impaired children with feeding problems and GER. This procedure solves these patients’ feeding problems even if the reflux is not completely eliminated. We advocate the use of this procedure in neurologically impaired patients with feeding problems and reflux due to its overall practicability and because there is minimal surgical trauma. This technique is extremely safe because the surgeon is able to verify, at the end of procedure, the status of the jejunostomy from outside and inside the abdominal cavity. The improvement in the quality of life of these children after the jejunostomy seems to be the major advantage of this procedure.

Pediatric laparoscopic splenectomy: are there real advantages in comparison with the traditional open approach?

The hospital records of patients who underwent splenectomy during the last 2 years were reviewed to compare the advantages of the laparoscopic approach with traditional open splenectomy (OS). Between March 1994 and March 1996, 16 children underwent splenectomy, in 8 using an open approach and 8 by a laparoscopic procedure. Of the patients who underwent laparoscopic splenectomy (LS), 2 had a concomitant cholecystectomy. Ages ranged between 4 and 11 years (mean 6.4 years); there were 9 girls and 7 boys. The indications for splenectomy were: hereditary spherocytosis (7 cases); idiopathic thrombocytopenic purpura (4); sickle-cell disease (3); and β-thalassemia (2). The average operating time for OS was 100 min (range, 50–155), for LS 170 min (range 125–240). The hospital stay for patients who had OS ranged from 3 to 9 days (mean 4.7), for those who had LS from 2 to 5 days (mean 3). One OS patient developed a wound infection. In 3 of the LS patients, the spleen was removed via a 7-cm Pfannenstiel minilaparotomy in the suprapubic region; in 5 cases the spleen was captured into an extraction bag, crushed, and removed through the umbilical orifice. The authors believe that LS must be performed only when it is possible to use the extraction bag to remove the spleen from the umbilical orifice (spleens weighing less than 700 g) and when a concomitant procedure such as cholecystectomy is indicated; in other cases OS is preferable.

Bochdaleck diaphragmatic hernia, complicated by an antenatal gastric perforation, presenting as a pneumothorax and a perforative peritonitis

The presentation of congenital diaphragmatic hernia (CDH) at birth may fall outside the typical features (cyanosis, tachypnea and respiratory failure), manifesting, instead, also with others pictures that make the diagnosis difficult or even impossible. We report a case of CDH presenting as a pneumothorax and a perforative peritonitis due to an antenatal gastric perforation.

One-trocar ileo-colic resection in a newborn infant with a cystic lymphangioma of the small-bowel mesentery.

We report a case of a newborn with a cystic lymphangioma of the small-bowel mesentery discovered antenatally at ultrasound and confirmed postnatally at computed tomography scan. The lesion together with the caecum and the last centimeters of ileum were resected by using only one trocar positioned lateroumbilically. In this paper, we describe the advantages of MIS to treat newborn with abdominal masses.

Clinical Aspects of Gastroesophageal Reflux in Infants and Children

Presenting features of gastroesophageal reflux (GER) in infants and children are quite variable and follow patterns of gastrointestinal and extra-gastrointestinal manifestations that vary between individual patients and may change according to age [1]. Patients may be minimally symptomatic, or may exhibit severe esophagitis, bleeding, nutritional failure, or severe respiratory problems [2].