Maria Escolino

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.

Current concepts in the management of inguinal hernia and hydrocele in pediatric patients in laparoscopic era

The surgical repair of inguinal hernia and hydrocele is one of the most common operations performed in pediatric surgery practice. This article reviews current concepts in the management of inguinal hernia and hydrocele based on the recent literature and the authors׳ experience. We describe the principles of clinical assessment and anesthetic management of children undergoing repair of inguinal hernia, underlining the differences between an inguinal approach and minimally invasive surgery (MIS). Other points discussed include the current management of particular aspects of these pathologies such as bilateral hernias; contralateral patency of the peritoneal processus vaginalis; hernias in premature infants; direct, femoral, and other rare hernias; and the management of incarcerated or recurrent hernias. In addition, the authors discuss the role of laparoscopy in the surgical treatment of an inguinal hernia and hydrocele, emphasizing that the current use of MIS in pediatric patients has completely changed the management of pediatric inguinal hernias.

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.

Laparoscopic management of a newborn with a right Amyand's hernia and a left incarcerated inguinal hernia

A one month old boy presented with left incarcerated inguinal hernia. After unsuccessful manual reduction, we decided to perform laparoscopic herniorrhaphy. Laparoscopic examination showed a left hernia with intestinal loops that entered into the internal inguinal ring, on the right side there was an unknown patency of the peritoneal vaginal duct with the appendix completely incarcerated within the sac. On the left side, the loops were reduced with a combined technique of external manual pressure and internal pulling by forceps; the bowel was inspected, and the hernia was repaired. On the right side, the appendix was strongly adherent with the peritoneal vaginal duct, and the reduction was not possible. The appendix was dissected from the sac using a 3-mm monopolar hook and than reduced into the abdomen, then right herniorrhaphy was performed. Two days after surgery, the baby had fever and abdominal distension. He was re-operated through mini-Pfannenstiel incision and an ischemic appendix was identified and removed. Postoperative period was uneventful. In our case, laparoscopy allowed for simultaneous reduction under direct visual control, inspection of the incarcerated organ, definitive repair and incidentally discovery and treatment of the contralateral incarcerated Amyand′s hernia. In case of incarcerated appendix, appendectomy is preferable during the same procedure to reduce the incidence of postoperative complications.

Risk of Malignancy and Need for Surgery in Pediatric Patients with Morris or Y-chromosome Turner Syndrome: A Multicenter Survey.

STUDY OBJECTIVE The management of intersex patients with Y-chromosome Turner or Morris syndrome remains a challenge. We report our experience with a multicenter European survey. DESIGN We collected the data on 18 patients (mean age 10.2 years, range 2-17 years) with Morris (10 patients) or Turner (8 patients) syndrome harboring the Y chromosome who were treated in 1 of 6 European centers of pediatric surgery between 1997 and 2013. All patients were evaluated by use of a multidisciplinary diagnostic protocol. All patients received a bilateral gonadectomy via laparoscopy; only 1 center performed ovarian cryopreservation. Seven patients received a concomitant genitoplasty. Operative notes and histology were reviewed for details. RESULTS No conversions to laparotomy and no complications were recorded. For the patients receiving only the gonadectomy, the length of hospital stay was 24-48 hours, whereas for the patients receiving an associated genitoplasty, it was 6-10 days. Specimens were negative for tumors in 83.3% of cases, whereas in 3 patients (16.6%), benign abnormalities (Sertoli cell hyperplasia in 1 patient and ovotestis in 2 patients) were recorded. A malignant tumor was not recorded in our series. CONCLUSION If the risk of malignancy is considered as the main indication for surgery in case of Turner or Morris syndrome, on the basis of our study, this indication should be reevaluated. However, based on the non-negligible rate of benign abnormalities reported in our series (16.6%), the performance of cryopreservation to preserve fertility and the possibility of performing genitoplasty during the same anesthetic procedure represent additional valid indications for surgery.

Retroperitoneoscopic Heminephrectomy in Duplex Kidney in Infants and Children: Results of a Multicentric Survey

PURPOSE Retroperitoneoscopic partial nephrectomy (RPN) in children is considered a complex technique with limited diffusion among pediatric surgeons and urologists. We aimed to report the outcome of this technique in infants and children with duplex kidney in a 5-year retrospective multicentric international survey. MATERIALS AND METHODS Data on 50 children who underwent RPN (41 upper-pole nephrectomies and 9 lower-pole nephrectomies) were retrospectively collected in this six-institution survey. Median age at surgery was 3.3 years. There were 35 girls and 15 boys. The left side was affected in 28 patients, versus the right side in 22 patients. We assessed intraoperative and postoperative morbidity. Follow-up (median, 2.5 years; range, 12 months-5 years) was based on clinical controls and echo color Doppler renal ultrasound scans. RESULTS Median duration of surgery was 255 minutes. Surgery was always performed with the patient in a lateral position. Special hemostatic devices were used for dissection and parenchymal section in all centers. Three patients from two centers (6%) required conversion to open surgery. We recorded seven complications (six peritoneal perforations, one opening of the remaining calyxes) in the 50 cases. Re-operation rate was 0%. Average length of hospital stay was 4.1 days. CONCLUSIONS Our survey shows that RPN remains a challenging procedure with a long learning curve, performed only in pediatric centers with huge experience in this field. In our survey operative time was longer than 4 hours. The complication rate remains high (7/50, or 14%), with complications classified as Grade II according to the Clavien-Dindo classification. They did not require further surgery, but they were associated with a prolonged hospital stay.

Evaluation and outcome of the distal ureteral stump after nephro-ureterectomy in children. A comparison between laparoscopy and retroperitoneoscopy

BACKGROUND In children with a poorly functioning kidney due to vesicoureteral reflux (VUR) or ureteropelvic junction obstruction, management is by nephrectomy with total or proximal ureterectomy. The complete removal of all the ureter minimizes the risk of future morbidity associated with the distal ureteral stump (DUS), including febrile urinary tract infections (UTIs), lower quadrant pain and hematuria, the so-called ureteral stump syndrome. OBJECTIVE To assess the outcome of the DUS after nephroureterectomy, we analyzed our recent experience of nephrectomy performed via retroperitoneoscopy and via laparoscopy. METHODS The records of 21 consecutive patients (median age 3.5 years, range 1-10 years) who underwent nephroureterectomy via laparoscopy or via retroperitoneoscopy were retrospectively reviewed for symptoms caused by DUS and their management. Nephrectomy was undertaken for a poorly functioning dysplastic (4), scarred from VUR (10) or hydronephrotic (7) kidney. In the laparoscopic group (11 pts), 6 cases required nephrectomy for reflux while 5 patients were operated for hydronephrotic or dysplastic non-functioning kidney. In the retroperitoneoscopic group (10 pts), nephrectomy was performed for reflux in 4 cases versus 6 patients affected by hydronephrotic or dysplastic non-functioning kidney. The patients were evaluated using ultrasound (US) to check DUS length and clinically to evaluate symptoms due to a symptomatic DUS. RESULTS The average length of surgery was 50 min for laparoscopy and 80 min for retroperitoneoscopy. The average of follow-up was 5 years. The length of DUS after laparoscopic nephrectomy was shorter (range 3-7 mm, statistically significant) than the DUS after retroperitoneoscopy (range 2-5 cm) (p < 0.001). Laparoscopic patients were all asymptomatic. Two patients, after retroperitoneoscopic nephrectomy, presented with recurrent UTIs; a voiding cystography revealed a VUR on the residual DUS and a redo surgery was performed in both the patients to remove the DUS (Figure). DISCUSSION Several authors have stated that, in case of subtotal ureterectomy, the incidence of symptomatic DUS after nephrectomy for high-grade vesicoureteric reflux is low. However, in our series, the incidence of symptomatic DUS after nephroureterectomy was not insignificant (2/21, 9.5%). Symptoms related to a refluxing DUS occurred only in patients undergoing retroperitoneoscopic nephroureterectomy, where the DUS was longer than the DUS detected in laparoscopic patients. CONCLUSIONS Considering that laparoscopy permits removal of all the ureter near the bladder dome, in children with non-functioning kidney due to VUR, it is advisable to always perform a laparoscopic rather than a retroperitoneoscopic nephrectomy to prevent problems related to a symptomatic DUS.

Engineering a human skin equivalent to study dermis remodelling and epidermis senescence in vitro after UVA exposure

Utra Violet type A (UVA) exposure strongly affects the ageing of human skin by modifying both epidermis and dermis and their cross talk as well. The possibility to get a deep understanding in vitro of such crucial mechanism would have a huge impact in the development of antiageing compounds. Here, we present a full thickness model of human skin equivalent formed by a millimeter‐sized dermis completely composed of fibroblasts embedded in their own extracellular matrix. We show that such endogenous nature of the dermis compartment allows the replication of the complexity of the mutual interactions occurring between cellular and extracellular components of the skin under UVA exposure: (a) oxidative stress formation in the whole tissue (dermis and epidermis); (b) senescence of germinative layer of epidermal tissue in terms of p63, ki67, and activated caspase‐3 regulation; (c) modification of the collagenous network architecture in the dermis compartment. By using this human skin model, it is possible to study a widely shared assumptions not yet proved in vitro such the effect of UVA on the self‐renewal capability of skin stem cells.

Malpractice in paediatric minimally invasive surgery – a current concept: Results of an international survey

This study aimed to assess malpractice in paediatric minimally invasive surgery (MIS), and attitudes, prevention strategies and mechanisms to support surgeons while they are under investigation. An observational, multicentric, questionnaire-based study was conducted. The survey questionnaire was sent via mail, and it comprised four sections. Twenty-four paediatric surgeons (average age 54.6 years), from 13 different countries, participated in this study. The majority had >15 years of experience in MIS. Three (12.5%) surgeons reported a total of five malpractice claims regarding their MIS activity. The reasons for the claims were a postoperative complication in 3/5 (60%) cases, a delayed/failed diagnosis in 1/5 (20%) cases and the death of the patient in 1/5 (20%) cases. The claims concluded with the absolution of the surgeon in all cases, and monetary compensation to the claimant in two (40%) cases. Eleven (45.8%) surgeons were invited as expert counsels in medico-legal actions. Medico-legal aspects have a minimal impact on the MIS activity of paediatric surgeons. In this series, claims concluded with the absolution of the surgeon in all cases, but they had a negative effect on the surgeon’s reputation and finances. A key element in supporting surgeons while they are under investigation is always to choose a surgeon who is an expert in paediatric MIS as legal counsel. A constant update on innovations in paediatric MIS and appropriate professional liability insurance may also play a key role in reducing medico-legal consequences.

Guidelines of the Italian Society of Videosurgery in Infancy for the minimally invasive treatment of the esophageal atresia

Not available.