Klaus Heller

Totally endoscopic Nissen fundoplication with a robotic system in a child.

A 67-year-old woman presented with severe cardiopulmonary insufficiency 17 days after an uneventful laparoscopic cholecystectomy. Pulmonary thromboembolism was demonstrated by transthoracic echocardiogram and later confirmed at surgery. With the aid of a cardiopulmonary bypass, a thrombectomy of the right atrium and the pulmonary artery was accomplished. The patient could not be weaned off cardiopulmonary bypass and ultimately died. We therefore recommend antithromboembolism therapy with low-molecular-weight heparin in selected cases of laparoscopic cholecystectomy.

Surgical treatment of tracheomalacia by bronchoscopic monitored aortopexy in infants and children.

BACKGROUND Aortopexy has become an established surgical procedure for the treatment of severe tracheomalacia (TM) in infancy. However, postoperative outcome may be improved by intraoperative bronchoscopic control of the aortopexy. METHODS Between 1992 and 2000, 16 infants and children (2 female, 14 male) with TM were treated by pexis of the aorta via a right (15 patients) or left (1 patient) anterior thoracotomy. Patients age ranged from 4 to 122 months (mean, 26 mon). Three infants had previous surgery for esophagus atresia and tracheoesophageal fistula. Another four patients were operated for gastroesophageal reflux. In all cases, the aortopexy was monitored intraoperatively by bronchoscopy. Respiratory function was verified for each patient by comparing pre- and postoperative tidal expiratory flow values (TEF 25% in ml/sec). RESULTS Mean follow-up was 36 months (range, 2 to 60 mo). There was no intraoperative or postoperative mortality. 13 patients showed permanent relief of symptoms. Postoperative median TEF 25% increased significantly compared with preoperative values (81 ml/sec vs. 56 ml/sec; p = 0.016). In one patient repeat aortopexy was necessary. CONCLUSIONS Aortopexy through a right anterior thoracotomy is an efficient and feasible method in the surgical treatment of TM in infancy and, therefore, can improve postoperative respiratory function. Intraoperative bronchoscopy is advantageous.

Surgeon’s occupational exposure to nitrous oxide and sevoflurane during pediatric surgery

Health hazards from occupational exposure to trace concentrations of anesthetic gases cannot be definitively excluded. The aim of the study was to determine the surgeon’s occupational exposure to nitrous oxide and sevoflurane during pediatric surgical procedures. Twenty young children (age <10 years) and five teenagers (age > 10 years) underwent elective abdominal surgery under general inhalational anesthesia. The operating room was equipped with modern air conditioning and waste anesthetic gas scavenger. Levels of both nitrous oxide and sevoflurane were determined in the breathing zone of the surgeon and the anesthesiologist during the operative procedures by means of a direct-reading photoacoustic infrared spectrometer. Both the surgeon and the anesthesiologist were exposed to low concentrations of the inhalational agents used. Exposure to sevoflurane and nitrous oxide was clearly higher during surgery in young children than during operative procedures in teenagers. Nonetheless, the concentrations of these agents were well below the threshold limits of 25 ppm for nitrous oxide and 2 ppm for sevoflurane recommended by the National Institute of Occupational Safety and Health. General anesthesia results in operating room air pollution with inhalational anesthetics. Under modern air conditioning, personnel’s occupational exposure is low, and inhalational anesthesia is safe from the standpoint of modern workplace laws and health care regulations. Nonetheless, all efforts must be taken to maintain occupational exposure at this low level.RésuméObjectives: Des risques en rapport avec l’exposition à des gaz d’anesthésie ne peuvent étre totalement écartés. Le but de cette étude a été de déterminer le risque qu’encourt le chirurgien avec le protoxyde d’azote et le sevoflurane pendant des procédés chirurgicaux pédiatriques. Méthodes: 20 enfants (âge≥ 10 ans) et cinq adolescents (âge≥ 10 ans) ont eu une intervention abdominale élective sous anesthésie générale par inhalation. La salle d’opération était équipée d’un système de ventilation moderne et d’une cartouche filtrante pour les gaz anesthésiques non utilisés. Les niveaux de protoxyde d’azote et de sevoflurane ont été déterminés dans l’environnement respiré par les chirurgiens et les anesthésistes pendant les opérations par un spectromètre infrarouge photo-acoustique de lecture directe. Résultats: Et le chirurgien et l’anesthésiste ont été exposés à des concentrations basses des agents utilisés. L’exposition au sevoflurane et au protoxyde d’azote était fortement plus élevée lorsqu’il s’agissait d’enfants plus jeunes par rapport aux adolescents. Néanmoins, les concentrations de ces agents étaient bien plus basses que les valeurs seuils de 25 ppm pour le protoxyde d’azote et de 2 ppm pour le sevoflurane, recommandées par le National Institute of Occupational Safety and Health. Conclusions: L’anesthésie générale provoque une certaine pollution de la salle d’opération par des produits d’anesthésie d’inhalation. Dans les conditions modernes de ventilation, l’exposition aux gaz est trés réduite et l’anesthésie d’inhalation peut être considérée comme un procédé sur d’un point de vue médico-légal et selon les réglementations des conditions de travail. Néanmoins, toutes les précautions doivent être prises pour maintenir les niveaux d’exposition à des niveaux les plus bas possibles.ResumenNo puede excluirse con certeza que la exposición, por motivos laborales a pequeñas concentraciones de gases anestésicos, pueda poner en peligro la salud de los profesionales. El objetivo de este trabajo fue determinar el grado de exposición de los cirujanos al óxido nitroso y al sevoflurano durante intervenciones quirúrgicas pediátricas. Métodos: 20 niños (menores de 10 años) y 5 adolescentes (mayores de 10 años) sufrieron una intervención quirúrgica abdominal bajo anestesia general por inhalación. El quirófano estaba equipado con una moderna instalación de aire acondicionado y un sistema eliminador de los gases anestésicos sobrantes. Utilizando un espectrómetro infrarrojo con lectura directa foto-acústica se determinaron los niveles de óxido nitroso y de sevoflurano en la zona en la que respiraban, durante la intervención, tanto el cirujano como el anestesista. Resultados: ambos, anestesista y cirujano, estuvieron expuestos a la inhalación a baja concentración de los agentes anestésicos utilizados. La exposición tanto al sevoflurano como al óxido nitroso fue significativamente superior durante la cirugía infantil que en las intervenciones quirúrgicas en adolescentes; sin embargo, ninguna de las concentraciones de los agentes anestésicos estuvieron por encima del umbral recomendado por el Instituto Nacional de Seguridad Laboral y Salud (25 ppm para el óxido nitroso y 2 ppm para el sevoflurano). Conclusiones: la anestesia general produce una polución del aire del quirófano cuando se utilizan anestésicos por inhalación. Si existe una moderna instalación de aire acondicionado, la exposición del personal laboral es muy baja y la anestesia por inhalación es segura, tanto desde el punto de vista de las modernas leyes laborales como de las regulaciones sobre atención sanitaria; a pesar de ello, no debe ahorrarse ningún esfuerzo para mantener la polución a estos bajos niveles.

Roboterassistierte, endoskopische Fundoplikatio nach Nissen bei Kindern: Hämodynamik, Gasaustausch und anästhesiologisches Management

ZusammenfassungIn der laparoskopischen Chirurgie stellt der Operationsroboter “da Vinci” die neueste Entwicklung dar. Wir berichten über die weltweit ersten 2 Mädchen im Alter von 10 und 12 Jahren, die sich einer endoskopischen Fundoplikatio nach Nissen mit diesem Robotersystem unterzogen haben. Während der gesamten Dauer der jeweils knapp 300-minütigen Allgemeinanästhesie erfolgte ein erweitertes hämodynamisches Monitoring, das aus invasiver Blutdruckmessung sowie arteriellen Blutgasanalysen in kurzen Abständen bestand. Wir konnten während der Operation – ein Pneumoperitoneum bestand bei beiden Kindern für 177 bzw. 180 min – keine relevanten Veränderungen von pH, paO2, paCO2, etCO2, Herzfrequenz und arteriellem Mitteldruck beobachten. Die Körpertemperatur wurde mit einer Wärmedecke aufrechterhalten. Unmittelbar nach Operationsende konnten beide Kinder extubiert und am 6. postoperativen Tag nach Hause entlassen werden. Ungeachtet der Tatsache, dass roboterassistierte Techniken die endoskopische Chirurgie entscheidend verbessern könnten, müssen trotz dieser ermutigenden Ergebnisse aufgrund der bislang niedrigen Patientenzahlen mögliche unerwünschte Auswirkungen der Roboterchirurgie als gegenwärtig nicht hinreichend geklärt betrachtet werden. Die Patienten bedürfen daher noch besonders intensiver – und somit auch invasiver –Überwachung und Aufmerksamkeit.AbstractThe robot device “da Vinci” represents the latest stage in laparoendoscopic surgery. We report the first two cases worldwide of endoscopic Nissen fundoplication with a telemanipulatory robot system in two children, aged 10 and 12 years. In addition to standard monitoring, we used invasive blood pressure monitoring during the 300 min periods of general anesthesia. Arterial blood gas samples were analyzed in short intervals. During surgery, which included 177 and 180 min periods of intraperitoneal insufflation of carbon dioxide, no significant changes of pH, PaO2, PaCO2, etCO2, heart rate, and mean arterial pressure were observed. Body temperature was maintained with an external warming blanket. Extubation was achieved immediately after the end of the operation, and both patients were discharged home on postoperative day 6. Robot-assisted techniques may possibly add significant progress and improvement to laparoendoscopic surgery. Nonetheless, we conclude that, despite our first encouraging results, potential risks of robot-assisted surgery have not yet been definitively defined. Therefore, patients are in need for intensive and even invasive monitioring, unless a larger number of patients has been studied.

Aortopexy in Infants and Children—Long-term Follow-up in Twenty Patients

BackgroundAortopexy has become an established surgical procedure for the treatment of tracheomalacia (TM) in infants and children. The aim of the present study was to evaluate the clinical outcome and respiratory function after aortopexy in the long term.MethodsBetween 1992 and 2006, 20 patients (6 female, 14 male) with TM were treated by bronchoscopically monitored pexis of the aorta via a right anterior thoracotomy. Patient age ranged from 4 months to 11 years (mean: 29 months). Five infants had previous surgery of esophageal atresia or tracheo-esophageal fistulae, and five other patients were operated on for gastroesophageal reflux. Postoperative tidal expiratory flow (TEF25%) was compared to age-related values.ResultsMean follow-up was 7.8 years (range: 13 months to 10.7 years). There was no early or late mortality. Most patients (n = 16) showed immediate and permanent relief of symptoms. Compared to corresponding age groups, median TEF25% was slightly but not significantly decreased after aortopexy (p = 0.15). In one patient a re-aortopexy was necessary. Another patient experienced recurrent tracheo-esophageal fistula 3 years after aortopexy.ConclusionsThe bronchoscopically guided aortopexy is an efficient and simple method in the surgical treatment of TM in infants and children. The follow-up data in this series of 20 patients showed improvement of respiratory function and permanent relief of symptoms in the long term.

Hemodynamic and Respiratory Effects of Robot-assisted Laparoscopic Fundoplication in Children

Laparoscopic fundoplication is increasingly used for treating gastro-esophageal reflux disease in children. Mechanical and pharmacological effects may contribute to hemodynamic and respiratory changes during carbon dioxide pneumoperitoneum. The aim of the present study was to evaluate the hemodynamic and respiratory effects of pneumoperitoneum (PP) with an intra-abdominal pressure (IAP) of 12 mmHg in children undergoing robot-assisted laparoscopic fundoplication during total intravenous anesthesia. Ten children, aged 8–16 years, American Society of Anesthesiologists physical status II–III, scheduled for robot-assisted laparoscopic fundoplication in the reverse Trendelenburg position were investigated. Minute ventilation (MV), peak inspiratory pressure (PIP), IAP, heart rate (HR), mean arterial blood pressure (MAP) were recorded, together with pH, base excess, HCO3−, PetCO2, PaCO2, and PaO2 at six time points: before insufflation, 10, 30, 60, 90 minutes after creating PP and after desufflation. The IAP was maintained at 12 mmHg. During insufflation MAP increased significantly from 70.6 (±9.0) to 84.8 (±10.4) mmHg, MV was increased from 4.6 (±0.8) to 5.5 (±0.9) lmin−1, PIP increased, PaO2 and pH decreased. PetCO2 increased from 33.1 (±1.6) to 36.6 (±1.6) mmHg together with PaCO2. Hemodynamic and respiratory effects due to the intra-abdominal insufflation of CO2 with an IAP of 12 mmHg are well tolerated, and anesthesia with remifentanil, propofol and mivacurium facilitates extubation immediately at the end of surgery.

Fasteninduzierte Ketoazidose bei einem 14 Monate alten Kleinkind

ZusammenfassungPräoperative Nüchternheit vor elektiven pädiatrischen Eingriffen wird routinemäßig als Aspirationsprophylaxe durchgeführt. Hypoglykämie, Durst und vermindertes Wohlbefinden sind mögliche unerwünschte Nebenwirkungen. Die metabolischen Veränderungen auf sinkende Blutzuckerspiegel bei fastenden Kindern umfassen die Glukoneogenese und die Produktion von Ketonkörpern zur Deckung des Energiebedarfs. Die Anhäufung von β-Hydroxybutyrat und Acetoacetat im Blut kann zur Azidose führen. Wir berichten von einer schweren intraoperativen Ketoazidose bei einem 14 Monate alten Kleinkind nach 36stündiger Nahrungskarenz.AbstractPreoperative starvation in order to prevent pulmonary aspiration is mandatory in elective pediatric surgery. Hypoglycemia, thirst and unwellness have been reported as undesired side effects. The metabolic response towards decreasing blood-glucose concentrations in fasting children includes gluconeogenesis and production of ketone bodys to meet the energetic demand. Accumulation of β-hydroxybutyrate und acetoacetate in blood can lead to ketoacidosis. We report a case of a severe intraoperative ketoacidosis in a fourteen months old child complicating 36 hours of starvation.

Use of the robot system DaVinci for laparoscopic repair of gastroesophageal reflux in children

In adult patients, laparoscopic surgery, using a robot system (Da Vinci, Intuitive Surgical, Mountain View, California), has been recently introduced into surgical practice. To investigate the feasibility of the system in paediatric surgery, laparoscopic fundoplications as well as cholecystectomies have been performed. In July 2000 we used the robot system for the first time on an 11-year-old girl with gastro-oesophageal reflux, and since that time on 7 other children. Altogether 5 Thal and 3 Nissen procedures have been carried out. The average age was 12 years, with a range of 7 to 16 years. All operations were performed without complications and without conversion to open surgery. The medium operating time was 146 min with a range of 105 to 180 minutes. Compared to conventional laparoscopy, the 3-dimensional high-quality vision, the advanced instrument movements and the ergonomic position of the surgeon seems to enhance surgical precision. In our opinion, the use of the robot system is feasible and safe in paediatric surgery. The technique is limited due to the fact that instruments adapted to the size of small children are not yet available.

A breathless toddler

A 3-year-old, previously healthy boy was admitted to hospital in September, 1992, in Turkey, where he was on holiday, with vomiting, fever, and dyspnoea. He had travelled to Turkey on a commercial airline 2 days before. During the flight, he drank three or four glasses of carbonated soft drinks. 2 h after take-off, he suddenly developed dyspnoea. On admission he was centrally cyanosed, had diminished breath sounds on the left side, and intercostal retraction. A chest radiograph was done, which was interpreted as showing a left-sided pneumothorax (figure). A pleural puncture on the midclavicular line in the sixth intercostal space did not lead to expansion of the left lung; however, a greenish fluid was aspirated. A second puncture on the midclavicular line in the second intercostal space also did not result in lung expansion. Further procedures, including placement of a nasogastric tube and upper gastrointestinal contrast radiography, showed that the air in the left hemithorax was air in a gastric bubble and in the duodenum. After returning to Germany by air ambulance, jet pressurised to sea level, the boy was successfully operated on, and a left-sided dorsolateral diaphragmatic hernia containing prolapsed stomach, part of the duodenum, spleen, and part of the left kidney, was closed. The left lung proved moderately hypoplastic and a non-rotation of the gut, which almost always accompanies congenital diaphragmatic hernia, was diagnosed. He was extubated 60 h after the operation, but had to be reintubated 12 h later because of respiratory insufficiency. 4 days later a further laparotomy became necessary as he developed an ileum invagination. 4 days after the second operation he was finally weaned from the ventilator. After 3 weeks of intensive physiotherapy, chest radiographs became normal. During air travel in commercial airliners, reduction of cabin pressure to about 595 mm Hg (2300 m) leads to a 30% increase in expansion of trapped gas volumes. Together with the consumption of carbonated soft CASE REPORT

Ketoacidosis in a 14 month old child caused by fasting

ZusammenfassungPräoperative Nüchternheit vor elektiven pädiatrischen Eingriffen wird routinemäßig als Aspirationsprophylaxe durchgeführt. Hypoglykämie, Durst und vermindertes Wohlbefinden sind mögliche unerwünschte Nebenwirkungen. Die metabolischen Veränderungen auf sinkende Blutzuckerspiegel bei fastenden Kindern umfassen die Glukoneogenese und die Produktion von Ketonkörpern zur Deckung des Energiebedarfs. Die Anhäufung von β-Hydroxybutyrat und Acetoacetat im Blut kann zur Azidose führen. Wir berichten von einer schweren intraoperativen Ketoazidose bei einem 14 Monate alten Kleinkind nach 36stündiger Nahrungskarenz.AbstractPreoperative starvation in order to prevent pulmonary aspiration is mandatory in elective pediatric surgery. Hypoglycemia, thirst and unwellness have been reported as undesired side effects. The metabolic response towards decreasing blood-glucose concentrations in fasting children includes gluconeogenesis and production of ketone bodys to meet the energetic demand. Accumulation of β-hydroxybutyrate und acetoacetate in blood can lead to ketoacidosis. We report a case of a severe intraoperative ketoacidosis in a fourteen months old child complicating 36 hours of starvation.