George W. Holcomb

Laparoscopic cholecystectomy in the pediatric patient

Since June 1990, five girls and one boy have been evaluated for biliary colic. Gallstones were documented by sonography. Two girls, ages 8 and 14 years, had hereditary spherocytosis, and a 9-year-old boy had sickle cell disease. The other three girls, ages 13, 13, and 15 years, developed cholelithiasis and biliary colic without a history of hematological disease. Three children weighed less than 90 lb, with the smallest weighing 45 lb. All patients underwent laparoscopic cholecystectomy without complications. Operative cholangiography was performed in five of the six children. The KTP-532 laser was used for dissection of the gallbladder from the liver bed in two patients, and electrocautery was used in the remaining four. The average operating time was 1 hour 45 minutes. This is a report of the use of laparoscopic cholecystectomy in pediatric patients. The advantages of its use include a shorter hospitalization, decreased postoperative discomfort, and a much shorter interval between the surgical procedure and return to normal activities such as school and play. At this time, it is recommended for those children without complications from their cholelithiasis such as common duct obstruction and gallstone pancreatitis.

Laparoscopic evaluation for a contralateral patent processus vaginalis

Between May 1, 1992 and March 1, 1993, 221 consecutively treated children under 10 years of age evaluated by the authors for a known inguinal hernia were involved in a prospective protocol to determine whether diagnostic laparoscopy has a place for evaluation of the contralateral inguinal region. Twenty-six had known bilateral inguinal hernias and did not require diagnostic laparoscopy. Of the other 195 children who underwent laparoscopy before hernia repair, 86 had a unilateral hernia with a contralateral patent processus vaginalis (CPPV), and 109 had only a unilateral hernia. After anesthesia, it was suspected on prelaparoscopic clinical examination that 55 patients had a CPPV. During laparoscopy, it was noted that 31 (56%) had patent processus vaginalis and 24 (44%) did not. Of the 140 patients believed to have a CPPV on prelaparoscopic clinical examination, 60 (43%) did and 80 (57%) did not. Insufflation alone was not diagnostic of CPPV; of the 195 patients undergoing laparoscopy, insufflation resulted in a positive finding on the known side in only 129 (66%) and on the contralateral side in 23 of the 86 patients (27%) found to have a CPPV. There were no complications related to the laparoscopy or the hernia repair.

Laparoscopic evaluation for a contralateral patent processus vaginalis: part III

OBJECTIVESnBetween May 1, 1992 and August 1, 1996, 759 consecutive children younger than 10 years of age were evaluated and treated for known inguinal hernia. These children were participating in a prospective investigation of the potential role of diagnostic laparoscopy in the evaluation of the contralateral inguinal anatomy. The initial two series of data (parts I and II of this three-part series) were previously presented at the 1993 and 1995 American Academy of Pediatrics meetings.nnnMETHODSnOf 759 patients, 100 children were diagnosed with bilateral inguinal hernias and therefore did not undergo laparoscopy. Thirty-two patients did not undergo laparoscopic evaluation due to technical difficulties or complicated clinical situations. The patients contralateral inguinal region was carefully examined under anesthesia, and predictions were made regarding the likelihood of contralateral patent processus vaginalis (CPPV). Six hundred twenty-seven children underwent diagnostic laparoscopy to confirm the presence or absence of CPPV. Laparoscopy was initially exclusively performed through the umbilicus prior to repair of the known hernia, but over the last 26 months, 250 children successfully underwent laparoscopy through the ipsilateral hernia sac.nnnRESULTSnOf patients younger than 1 year of age, 114 were diagnosed with both a known unilateral hernia and CPPV, whereas 132 had a unilateral hernia only (46% versus 54%). Among children older than 1 year of age, 148 (39%) were diagnosed with unilateral hernia and CPPV, and 233 (61%) were diagnosed with a unilateral hernia alone. After examination under anesthesia, 233 of the 627 patients were suspected of having a CPPV, and 107 were confirmed at laparoscopy (46%). The remaining 394 patients were not believed to have a CPPV. Normal inguinal anatomy was confirmed in 234 patients (59%), but 160 patients were found at laparoscopy to have a CPPV (41%).nnnCONCLUSIONSnA contralateral patent processus vaginalis may be present in a surprising number of young patients being evaluated for a known inguinal hernia. Laparoscopy can be performed without a separate incision when the ipsilateral hernia sac is of sufficient width to allow passage of the scope. Laparoscopy is the best method for evaluating the contralateral inguinal region, particularly in younger children, as it prevents unnecessary inguinal exploration and it decreases the risk that the child will later present with a clinical contralateral hernia.

Laparoscopic evaluation for contralateral patent processus vaginalis: Part II

Between May 1,1992 and August 1, 1995, 599 consecutively treated children under 10 years of age evaluated by the authors for a known inguinal hernia were involved in a prospective protocol to determine whether diagnostic laparoscopy has a place for evaluation of the contralateral inguinal region. The experience with the first 221 patients was reported at the 1993 AAP meeting. In this total experience, 81 patients had known bilateral inguinal hernias and did not require diagnostic laparoscopy. Five hundred eighteen patients had a unilateral inguinal hernia with the status of the contralateral region being unknown. Between May 1, 1992 and May 1, 1994, 368 children underwent evaluation using an umbilical approach. However, for the past 14 months, 150 patients have undergone the diagnostic laparoscopy through the ipsilateral hernia sac. Among the children under 1 year of age, 98 were found to have a unilateral hernia and also a contralateral patent processus vaginalis (CPPV) and 110 had a unilateral hernia. Of the children older than age 1,116 had a unilateral hernia and CPPV and 194 had only a single hernia. After induction of anesthesia, it was suspected on clinical examination that 195 of the 518 patients had a CPPV. However, laparoscopy showed that only 94 (48%) had a CPPV. In the remaining 323 patients, the surgeon believed that a CPPV was not present based on the examination. This negative finding was verified in only 198 patients (81%), but a surprising 125 (39%) did have CPPV documented at the time of endoscopy. Insufflation alone was very unrellable for documenting the presence of CPPV. Of the 214 patients for whom CPPV on the contralateral side was documented during laparoscopy, only 41 (19%) had a positive finding on insufflation. This experience has convinced the authors that diagnostic laparoscopy is the most accurate means to ascertain whether a patient should undergo contralateral inguinal exploration. In addition, laparoscopy through the ipsilateral inguinal sac is now the preferred approach.

Laparoscopic surgical treatment of achalasia

BACKGROUNDnThe authors have performed 11 myotomies in 10 patients (aged 12 to 77) with achalasia using minimally invasive techniques.nnnMETHODSnThe initial 3 patients were treated via transthoracic approach; the subsequent 7 patients via transabdominal approach. The length of the myotomy was determined in conjunction with intraoperative endoscopy to facilitate dissection and demonstrate division of the lower esophageal sphincter.nnnRESULTSnOnly 1 patient required intravenous and intramuscular narcotics more than 24 hours postoperatively; 2 patients required no postoperative narcotics. The average hospital stay for those patients successfully treated endoscopically averaged 2.0 +/- 0.5 days (range 1.5 to 3). One patient was converted to open thoracotomy secondary to perforation of the mucosa. One patient required repeat laparoscopic myotomy at 3 months due to recurrent dysphagia. Follow-up conducted at clinic visits showed all patients to have benefitted with relief of dysphagia; 80% (8) reported excellent results, 10% (1) reported good results, and 10% (1) fair results.nnnCONCLUSIONnWe converted from thoracic to laparoscopic myotomy because the abdominal approach simplified anesthetic and surgical management. We conclude that laparoscopic myotomy is a simple and effective treatment of achalasia.

Laparoscopic cholecystectomy in infants and children: modifications and cost analysis.

Between June 1990 and February 1993, 26 children underwent laparoscopic cholecystectomy. Their ages ranged from 25 months to 19 years (mean, 12.3 years; median, 13 years). Only six of them had hemolytic diseases associated with gallstones. Five presented with acute cholecystitis. Laparoscopic cholecystectomy was performed on these five, within 5 days of admission; the mean postoperative hospital stay was 2.5 days. The other 21 patients underwent elective cholecystectomy; their mean postoperative stay was 1 day. Several modifications have been made in our technique. Three 5-mm ports and one 10-mm umbilical port are used. In addition, direct incision of the umbilical fascia is performed with insertion of a blunt trocar and cannula rather than using the Veress needle for insufflation. The importance of positioning the epigastric cannula in the left upper quadrant in small children cannot be overemphasized. Cholangiography is now attempted in all patients and is easier with the Kumar cholangioclamp and sclerotherapy needle, under fluoroscopy. The total hospital charges for the patients who underwent elective laparoscopic cholecystectomy are compared retrospectively with those of seven children who had elective open cholecystectomy during the same period. In addition, a comparison is made between the two groups with respect to the costs of operating room equipment and postoperative pain control.

MINIMALLY INVASIVE SURGERY FOR SOLID TUMORS

The use of minimally invasive surgery in patients with cancer is slowly evolving. There are a number of reports describing laparoscopy in adults for pancreatic, ovarian, gastric, and colon cancers. In addition, thoracoscopy has been described for lung and esophageal cancers. The role of laparoscopy and thoracoscopy in children with cancer is less clear because a number of pediatric neoplasms are sensitive to adjuvant therapy and surgery is often part of a planned multi-dimensional approach. This article describes a previous reported experience with minimally invasive surgery in children with cancer, current indications for this approach, and general principles which are important regarding the operative technique. In addition, future applications for this technology are suggested.

Laparoscopic Esophagomyotomy for Achalasia in Children

Achalasia is an uncommon condition in children. The authors report on two children who were evaluated and treated with laparoscopic esophagomyotomy. A 6-port technique was used, with five 5-mm ports and one 10-mm port. During the procedure, esophagoscopy was performed simultaneously, which provided esophageal distension for easier dissection and aided the surgeon by documenting when a complete myotomy had been accomplished. The patients symptoms have resolved, and no postoperative complications have developed. Laparoscopic esophagomyotomy can be performed safely in children and is an effective approach for treatment of this disorder. Its advantages over the open approach include shorter hospitalization and less discomfort.

Laparoscopic left adrenalectomy for pheochromocytoma in a child

Although uncommon, adrenalectomy occasionally is indicated in children. To date, this procedure has required either a laparotomy or a flank incision. The authors report the case of a child with episodic palpitations, diaphoresis, chest discomfort, and occipital headache who underwent laparoscopic adrenalectomy for pheochromocytoma without complication.

Diagnostic Laparoscopy for Congenital Inguinal Hernia

Repair of indirect inguinal hernias is the most common general surgical procedure in infants and children. The question of whether or not to explore the contralateral side, however, has been the source of much debate among pediatric surgeons. With the advent of laparoscopy and the development of miniature telescopes, diagnostic laparoscopy has been advocated to decide in which child the contralateral side should be explored and a patent processus vaginalis ligated. This article describes the historical perspective in which this technique developed, the technique itself, and a report of the authors experience. Copyright