Ida Giurin

Open Versus Laparoscopic Appendectomy in the Pediatric Population: A Literature Review and Analysis of Complications

BACKGROUND This study aims to compare the results of laparoscopic and open appendectomy (LA and OA, respectively) in a pediatric population with particular attention to complications analysis. SUBJECTS AND METHODS A literature search was performed using Medline, Cochrane, Embase, Sci Search, Lilacs, and PubMed databases on all studies published during the 14-year interval of 1997-2010. Comparative studies of LA versus OA in the pediatric population were included in these studies. Data concerning operative time, length of hospital stay, postoperative complications, postoperative pain, and surgical trauma were recorded. RESULTS We recorded 52 studies, but 26 of these were excluded from our analysis because they were neither relevant nor related to the adolescent population. The 26 studies analyzed showed a population of 123,628 children and adolescents (ages 0-18 years) who underwent appendectomy by laparoscopic (LA, 42,213 [34.1%]) and open (OA, 81,415 [65.9%]) techniques. Our analysis showed that patients undergoing LA presented a lower incidence of surgical wound infection, lower incidence of postoperative ileus, a lower use of analgesics in the postoperative period, an earlier resumption of normal diet, a shorter hospitalization, and a more rapid recovery to resume normal activities compared with patients undergoing OA. This study, comparing LA versus OA in children, failed to identify any major difference between the two techniques in terms of formation of intra-abdominal abscesses. As for operative time, our analysis showed globally a significant reduced operative time in OA versus LA in complicated appendicitis, but in simple appendicitis the operative time seems to be the same. CONCLUSIONS Our analysis of the literature showed that the LA technique presents several advantages compared with the OA technique. For this reason, if a child is hospitalized today for appendicitis treatment in a pediatric center where the laparoscopic approach is unavailable, he or she should be placed on antibiotics and transferred to a center that offers the laparoscopic approach.

Long-Term Outcome of Laparoscopic Nissen Procedure in Pediatric Patients with Gastroesophageal Reflux Disease Measured Using the Modified QPSG Roma III European Society for Pediatric Gastroenterology Hepatology and Nutrition's Questionnaire

BACKGROUND/PURPOSE Laparoscopic fundoplication (LF) represents the gold standard for surgical treatment for pediatric patients with gastroesophageal reflux disease (GERD). METHODS We report the results of long-term outcome of 36 patients who had undergone LF from January to December 1998, with a follow-up longer than 10 years (range, 11-12 years). The patients were invited, by phone, to undergo a clinical follow-up. All patients underwent the modified European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)s Roma III questionnaire; however, only 22 out of 36 patients accepted to be controlled in a day hospital setting, and 10 out of 36 accepted to undergo a telephonic questionnaire. Our study is focused on the data of these 32 patients. RESULTS Twenty-eight out of 32 (87.5%) patients had completely recovered; 4 out of 32 patients (12.5%) had a mild persistent GER; 9 out of 32 patients (28%) referred a mild dysphagia; 21 out of 32 (66%) patients could burp; and only 9 out of 32 (28%) patients could vomit. The cosmetic result was good in 30 out of 32 (94%) patients. The weight/height ratio was satisfactory in 28 out of 32 (87.5%) patients. The quality of life was good in 28 out of 32 (87.5%) patients. CONCLUSIONS Our experience shows that the long-term follow-up after LF produces a good clinical result and a good quality of life. The modified ESPGHANs Roma III questionnaire seems an effective way to check the long-term results, because it avoids submitting patients to long and not well tolerated instrumental exams.

Technical Standardization of Laparoscopic Direct Hernia Repair in Pediatric Patients

BACKGROUND The aim of this article is to standardize the laparoscopic technique to treat direct inguinal hernia in pediatric patients. PATIENTS AND METHODS In the last 3 years we treated laparoscopically 163 patients with a diagnosis of inguinal hernia. In 7 patients we discovered laparoscopically a direct inguinal hernia. This study is focused on the management of these 7 cases (4 girls and 3 boys; median age 4.6 years). They presented a right defect in 4 cases and a left defect in 3 cases. Six of 7 patients had been already operated for an inguinal hernia and presented a recurrence of the hernia. We used three trocars, 5-mm 0 degree optic, and two 3-mm instruments. In each case, after the resection of the lipoma using the hook cautery, the defect was closed by means of separated stitches. In every case we used the vesical ligament as an autologous patch to reinforce the closure of the defect. RESULTS The average operative time was 35 minutes. All the procedures were performed in a day-hospital setting. We had neither conversions nor complications in our series. With a minimum follow-up of 1 year, we had no recurrence. CONCLUSIONS Laparoscopic identification and repair of direct inguinal hernia in children is a safe and effective procedure to adopt. The key points of the technique are the resection of the lipoma, the closure of the defect using separated, nonabsorbable sutures, and the use of the vesical ligament to reinforce the suture. We believe that in case of recurrence of inguinal hernias after inguinal approach, laparoscopy is the gold standard technique to identify and treat the cause of the recurrence itself.

Preputioplasty associated with urethroplasty for correction of distal hypospadias: A prospective study and proposition of a new objective scoring system for evaluation of esthetic and functional outcome

OBJECTIVE Most surgical procedures for correction of hypospadias involve the removal of foreskin resulting in a circumcised penis. We report our experience and the medium-term results in the reconstruction of the foreskin during the correction of distal hypospadias. MATERIALS AND METHODS Between January 2007 and December 2011, 445 patients aged between 8 and 120 months underwent surgical correction of hypospadias. In 354 out of 445 patients, we performed the reconstruction of the foreskin. Urethroplasty was performed according to either the TIPU (tubularized incised urethral plate urethroplasty; Snodgrass) technique (233/354, 66%) or MAGPI (meatal advancement glanduloplasty incorporated) procedure (121/354, 34%). In 91 out of 445 patients urethroplasty was performed using classic TIPU technique and they were circumcised. The cosmetic and functional results were evaluated using the Hypospadias Objective Penile Evaluation (HOPE) scoring system. RESULTS At a 12 months follow-up, 300 patients (84.7%) had retractable foreskin while 54 patients (15.3%) required postoperative steroid application. We had a total complication rate of 8.7%. As for preputioplasty, 16 patients (4.5%) had partial or total dehiscence of the reconstructed foreskin, one patient was circumcised for persistent phimosis (0.2%). As for urethroplasty complications, we recorded 11 fistulas (3.1%) and three stenosis (0.9%). The complication rate of the control group of circumcised patients was of 3.3% (2 fistulas [2.1%] and 1 stenosis [1.2%]). CONCLUSIONS Our experience shows that foreskin reconstruction can be performed successfully in selected patients with distal hypospadias. However, preputioplasty add an additional 4.7% complication rate. As for the complications of urethroplasty, it seems that preputioplasty does not increase the incidence of complications on the urethra reconstruction. We propose a new objective scoring system (modified HOPE score) for evaluation of esthetic and functional outcome.

Blue Patent Lymphography Prevents Hydrocele After Laparoscopic Varicocelectomy: 10 Years of Experience

PURPOSE Laparoscopic varicocelectomy according to the Palomo technique is the most common procedure adopted in children with testicular varicocele. This procedure involves the ligation of the internal spermatic cord and is associated with a 3%-5% incidence of recurrence and up to 30% incidence of hydroceles. We sought to determine the impact of lymphatic preservation on hydrocele formation and the success of varicocelectomy. PATIENTS AND METHODS We retrospectively evaluated 396 patients with a mean age of 13.2 years who underwent laparoscopic varicocelectomy. Patients were divided into two groups: those who underwent a lymphatic-sparing (LS) procedure using isosulfan blue scrotal intra-dartoic injection and those who underwent a non-LS (NLS) technique. The incidences of recurrence/persistence and postoperative hydrocele formation requiring surgery or aspiration were analyzed statistically using the chi-squared test. RESULTS Of 396 patients, 244 received a laparoscopic LS procedure, and 152 received an NLS operation. The LS patients in whom the lymphatic vessels were not identified (26/244 [10.6%]) were considered NLS repairs. The follow-up was at least 12 months. LS surgery (218 patients) was associated with a decreased incidence of postoperative hydrocele (0/218 [0%] versus 18/178 [10.1%]; chi-squared test=25.84, difference statistically significant). There was no significant difference in incidence of persistent or recurrent varicocele requiring reoperation following the initial procedure (5/218 [2.2%] versus 5/178 [2.8%]; chi-squared test=0.41, difference statistically not significant). CONCLUSIONS Laparoscopic LS varicocelectomy using isosulfan blue is preferable to laparoscopic Palomo repair that does not preserve the lymphatics. It has a significantly lower incidence of postoperative hydroceles and still maintains a low incidence of persistence/recurrence.

Non-prosthetic Surgical Repair for Pectus Deformities

Chest wall malformations (CWMs) represent a wide range of pathologies. Pectus excavatum and carinatum anomalies are the most common. Considering the importance of evaluate the benefits and the limitations of each technique, surgical procedures and postoperative cares have developed. The use of a metal bar for sternal stabilization was introduced in 1956 and remains the most widely used. In recent years a minimally invasive technique of pectus excavatum repair using a convex steel bar to force the sternum forwards has gained popularity. A number of complications have been reported with the use of the metal bar, notably displacement (5.8 %), allergy to the bar (2.9 %) and excavatum overcorrection (3.2 %). Other less frequent complications include prosthesis infection, pneumonia, pleural effusion, haemothorax, wound seroma, skin necrosis, pericarditis and cardiac perforation. An additional operation is also required to remove the bar. Recently some authors have described a prosthesis-free technique for the surgical treatment of pectus excavatum, in which the position of the sternum is supported by the attachment to the overlying muscle raphe holding it in the desired position, assisted by maintenance of good posture after surgery. This produce a stable repair with no evidence of a postoperative flail chest. This technique has been utilised for the surgical treatment of pectus carinatum too. The only limitation is the short follow-up (under 4 years). Long-term follow-up will determine the durability of the techniques.

Idiopathic scrotal hematoma simulating a testicular torsion, in association with cryptorchidism: US findings

Summary Background An acute scrotum concerns endoscrotal organs (testicles, spermatic cord, tunica vaginalis) and is characterized by pain, swelling and hyperemia of the hemi-scrotum. It represents one of the most common surgical emergencies in children often caused by testicular torsion; the diagnosis is mostly clinical but must be supported by ultrasonographic examination of the scrotal region in association with a colour Doppler study of the spermatic cord vessels and glandular parenchyma. An idiopathic scrotal hematoma is a very rare condition that can simulate it. Case Report A 3-day-old full-term baby, otherwise in good health, showed swelling and pain of the left inguinal-scrotal region. A testicular torsion was suspected, so the baby underwent an ultrasound examination of the testis and spermatic cord that showed a left scrotal hematoma with superior displacement of the didymus; the right testicle was located in the internal inguinal canal. Surgical intervention confirmed the sonographic diagnosis of left testicular hematoma and of the right cryptorchidism. Conclusions Although testicular torsion is the most frequent cause of acute scrotum, the possibility of a persistent idiopathic scrotal haematoma and/or haematoma secondary to a trauma of the inguino-scrotal region, must be always taken into account. US diagnosis can avoid unnecessary emergency surgical treatment, required in case of testicular torsion.

P213 - Traitement laparoscopic de l’hernie inguinal dans la première année de vie

Introduction notre experience dans la cure d’hernie inguinale par voie laparoscopique dans la premiere annee de vie, pour souligner les avantages de la procedure dans cet âge. Methodes Dans une periode de 2 ans, nous avons traites 315 patients avec hernie inguinale unilaterale par vois laparoscopique et 50 avaient moins de 1 annee. Notre attention sera concentree sur ce groupe de 50 enfants. Le rang d’âge etait de 1 jusqu’ a 12 mois avec un poids median de 5,5 kg. 5/50 patients ont presente une hernie incarceree. Nous avons utilise la technique de Montupet modifie. Resultats temps operatoire : 22 minutes. 35 procedures effectuees en hopital de jour, 15 patients dechargees le jour apres le procede. Dans 22 patients on a trouve une perviete contralateral et on a realise une herniorraphie bilateral. Dans une fille il y avait la coexistence d’une hernie oblique externe, une hernie directe du cote droit et les deux orifices ont ete sutures en laparoscopie. Au follow up minimum de 1 an il y avait 1 recidive sur 73 herniorraphies. Conclusions dans notre experience la reparation laparoscopique de l’hernie inguinale dans les enfants au dessous de 1 an par les mains expertes est une procedure efficace, qui permet de soigner au meme temps toutes les formes d’hernies inguinales.

CL072 - Suivi a long-terme dans les enfants opérés par un RGO étudiés avec le questionnaire QPSG Roma III ESPGHAN

Introduction La fundoplicature laparoscopique selon Nissen (LF) represente le gold standard chez les enfants avec la maladie de reflux gastroesofagienne apres echeque du traitement medical. Materiels et Methodes 36 enfants operes avec une LF entre janvier et decembre 1998; follow-up au moins de 10 ans. 4 malades, indisponibles, ont ete exclus de l’etude. Les autres 32 ont ete invites par telephone a repondre au questionnaire de Roma III de l’ESPGHAN modifie et a effectuer un control clinique. Tous les patients ont repondu au questionnaire et seulement 22/32 ont acceptes le control clinique. Resultats 29 patients n’avaient plus des symptomes; 3 avaient un GOR persistant modere ; 7 presentent encore une dysphagie minimale ; 26 pouvaient eruttes et seulement 10 pouvaient vomir. Le resultat cosmetique etait excellent dans 20/22. Le rapport poids/taille etait satisfaisant dans 30. La qualite de vie etait bonne dans 29. Conclusions Notre experience prouve que la FL donne des bons resultats clinique et une bonne qualite de vie. Le questionnaire de ROMA III DE L’ESPGHAN modifie semble une facon efficace de verifier les resultats a long terme ; il laisse verifier les resultats par le telephone et evite de soumettre les patients aux examens instrumentaux ne pas bien toleres.