Oliver J. Muensterer

Laparoscopic Adrenalectomy in Children: A Multicenter Experience

INTRODUCTION Laparoscopic adrenalectomy is now being recognized as the standard approach for adrenalectomy for benign lesions in adults. The published experience in children and adolescents has been limited to sporadic small case series. Therefore, we conducted a large multicenter review of children who have undergone laparoscopic adrenalectomy. METHODS After Institutional Review Boards approval, a retrospective review was conducted on all patients who have undergone laparoscopic adrenalectomy at 12 institutions over the past 10 years. Operative times included unilateral adrenalectomy without concomitant procedures. RESULTS About 140 patients were identified (70 males [50%]). Laterality included 76 (54.3%) left-sided lesions, 59 (42.1%) right, and 5 (3.6%) bilateral. Mean operative time was 130.2 ± 63.5 minutes (range 43-406 minutes). The most common pathology was neuroblastoma in 39 cases (27.9%), of which 23 (59.0%) had undergone preoperative chemotherapy. Other common pathology included 30 pheochromocytomas (21.4%), 22 ganglioneuromas (15.7%), and 20 adenomas (14.3%). There were 13 conversions to an open operation (9.9%). Most conversions were because of tumor adherence to surrounding organs, and tumor size was not different in converted cases (P=.97). A blood transfusion was required in 2 cases. The only postoperative complication was renal infarction after resection of a large neuroblastoma that required skeletonization of the renal vessels. At a median follow-up of 18 months, there was only one local recurrence, which was in a patient with a pheochromocytoma. CONCLUSIONS The laparoscopic approach can be applied for adrenalectomy in children for a wide variety of conditions regardless of age with a 90% chance of completing the operation without conversion. The risk for significant blood loss or complications is low, and it should be considered the preferred approach for the majority of adrenal lesions in children.

Pediatric firearm injuries: A 10-year single-center experience of 194 patients

BACKGROUND The objective was to investigate the relationship of high gun ownership and gun death rate on children and determine predictors influencing the incidence and outcome of pediatric firearm injuries in a major pediatric level 1 trauma center. METHODS We performed a retrospective review of our trauma registry to identify hospital admissions between April 1999 and March 2010. We extracted demographic and geographic data, seasonal variation, injury type, firearm type, and outcome. RESULTS We identified 194 firearm injuries. The incidence did not change during the past decade. Most occurred during the second half of the year (61.4%). Mean age was 12.2 ± 4.6 years (range, 0.4-19.2 years). Unintentional shootings accounted for 100 injuries followed by assaults (n = 55) and innocent bystanders (n = 39). African American children were most often injured because of a violent cause (60.3%), whereas white children were shot unintentionally (80.1%). Powder-propelled firearms caused 82.5% of injuries. Overall, 17.5% of children required an operation, and 9.3% died. CONCLUSIONS The overwhelming majority of children were injured after a gun went off unintentionally, whereas most African American children were shot violently. We identified certain seasonal and geographic clusters. These data can be used to target gun injury prevention programs.

An evidence-based clinical protocol for diagnosis of acute appendicitis decreased the use of computed tomography in children

PURPOSE The increased use of computed tomography (CT) to diagnose appendicitis in children has led to a concern for the possibility of increased CT-related cancer morbidity. We designed a clinical protocol for the diagnosis and treatment of appendicitis in children in an attempt to decrease the use of CT scans at our institution. METHODS Patients who had surgical consultation for suspected appendicitis were placed on the clinical protocol. Data concerning diagnosis and treatment were collected prospectively. Retrospective data from patients admitted to our institution with acute appendicitis before the clinical protocol were collected as historical controls. RESULTS One hundred twelve patients were diagnosed and treated by our protocol between June and November 2009. Of these, 100 patients underwent an appendectomy for acute appendicitis. They were compared with 146 patients from 2007. In-house CT use decreased from 71.2% to 51.7% (P = .01). Preoperative ultrasound use increased from 2.7% to 21% (P < .001). The negative appendectomy rate increased (6.8% vs 11%, P = .25). CONCLUSIONS Our findings suggest that the implementation of an evidence-based clinical protocol for the diagnosis and treatment of acute appendicitis in children may safely decrease the use of CT scans and increase the use of ultrasound.

Effects of multidisciplinary prenatal care and delivery mode on gastroschisis outcomes

BACKGROUND/PURPOSE This study examined the effects of multidisciplinary prenatal care and delivery mode on gastroschisis outcomes, with adjustment for key confounding variables. METHODS This retrospective cohort study included all gastroschisis patients treated at a single tertiary childrens hospital between 1999 and 2009. Prenatal care, delivery mode (vaginal vs cesarean section before labor vs after labor), patient characteristics, and clinical outcomes were determined by chart review. Time to discontinuation of parenteral nutrition (PN) was the primary outcome of interest. Effects of multidisciplinary prenatal care and delivery mode were evaluated using Cox proportional hazards regression models that included gestational age, birth weight, sex, concomitant intestinal complications, and year of admission. RESULTS Of 167 patients included, 46% were delivered vaginally, 69% received multidisciplinary prenatal care, and median time to PN discontinuation was 38 days. On multivariable modeling, gestational age, uncomplicated gastroschisis, and year of admission were significant predictors of early PN independence. Delivery mode and prenatal care had no independent effect on outcomes, although patients receiving multidisciplinary prenatal care were more likely to be born at term (49% vs 27%, P = .01). CONCLUSIONS Gestational age and intestinal complications are the major determinants of outcome in gastroschisis. Multidisciplinary prenatal care may facilitate term delivery.

Single-Incision Pediatric Endosurgery for Ovarian Pathology

BACKGROUND AND OBJECTIVES Despite being pioneered by gynecologists, single-incision endosurgery has not been widely reported for the treatment of ovarian and adnexal pathology in neonates, children, and adolescents. We describe our initial experience using single-incision pediatric endosurgery (SIPES) for these indications and discuss advantages and drawbacks. SUBJECTS AND METHODS All children who underwent SIPES with a preoperative diagnosis of ovarian or adnexal pathology were included in the study. Data on age, operative time, complications, length of hospital stay, and outcomes were collected. RESULTS From January 2010 until January 2012, 19 girls (mean age, 11.4 years; range, 6 days-17 years; weight range, 4.0-90 kg) underwent SIPES procedures for ovarian or adnexal diagnoses, including hemorrhagic/follicular/paratubal cysts (n=8), torsion (n=7), tumor (n=3), and parauterine cyst (n=1). The operations included cyst unroofing (n=4), detorsion and oophoropexy (n=7), (salpingo)oophorectomy (n=5), marsupialization of cyst (n=2), and cyst aspiration (n=1). Median operative time was 42 ± 29 minutes; there were no conversions to conventional laparoscopy or open surgery. Fifteen patients (79%) were discharged within 24 hours after the procedure. There were no peri- or postoperative complications. Histopathology showed hemorrhagic/follicular/paratubal cyst (n=7), necrotic/calcified ovarian tissue after torsion (n=6), cystadenofibroma (n=1), granulosa cell tumor (n=1), and mature teratoma (Grade 0) (n=1). CONCLUSIONS SIPES is an excellent alternative to conventional laparoscopy for the treatment of adnexal pathology. Using a single umbilical incision that can be enlarged instead of three smaller trocar sites facilitates the resection and extraction of ovarian masses without compromising cosmesis.

Feasibility of Single-Incision Pediatric Endosurgery for Treatment of Appendicitis in 415 Children

INTRODUCTION Single-incision pediatric endosurgery (SIPES) has gained popularity for ablative procedures such as appendectomy in many pediatric surgical centers. This study evaluates the outcome of SIPES for treatment of appendicitis in our institution. PATIENTS AND METHODS After Institutional Review Board approval was obtained, data were prospectively collected on all patients undergoing SIPES appendectomy in our hospital from March 2009 through October 2011. The surgical techniques, operative times, complications, conversion rates, and outcomes were recorded. RESULTS SIPES appendectomy was attempted in 415 children (mean age, 10.9 years; age range, 1.4-17.9 years; 266 males, 149 females; median weight, 43 kg; weight range, 9.8-146 kg). Intraoperatively, acute appendicitis was found in 298 cases and perforated appendicitis in 79 cases. Thirty-eight patients underwent interval appendectomy. Appendectomy was carried out solely as SIPES in 397 cases (96%). Median operative time was 40±16 minutes (37±16 minutes for fellows [n=284] and 46±15 minutes for residents [n=131]). There were three intraoperative complications, which could be handled during the procedure. Pathologic reports revealed inflammatory changes of the appendix (n=386), other pathology (n=11), and no pathologic change (n=18). Overall, 24 patients (5.8%) were readmitted for intra-abdominal abscess (n=14), umbilical wound infection (n=3), and other reasons (n=7). Twelve patients (2.9%) underwent reoperation: drainage of intra-abdominal abscess (n=8) (3 by the surgeon, 5 by the interventional radiologist), wound drainage (n=3), and right hemicolectomy for carcinoid (n=1). In perforated appendicitis the postoperative intra-abdominal abscess rate was 10 of 79 cases (12.7%), which is similar to the previous report with conventional laparoscopic appendectomy from our institution (13.6%). The wound infection rate (5 of 79 cases [6.3%]) was also similar to the previously report (6.8%) with conventional laparoscopic appendectomy for perforated appendicitis. CONCLUSIONS Appendectomy can be accomplished successfully and safely using single-incision endosurgery in children with acceptable operative times without leaving any appreciable scar. Additional trocars are infrequently necessary. So far, the intraoperative and postoperative complication rates are comparable to those of triangulated laparoscopic appendectomy.

Resection of a duodenal web using single-incision pediatric endosurgery

Single-incision pediatric endosurgery (SIPES) is used in many centers for routine cases such as appendectomies and cholecystectomies, but more complex procedures are still infrequently performed. We report the case of a 9-month-old girl with Down syndrome diagnosed with a duodenal web who underwent duodenal web resection and tapering using a SIPES technique. The procedure was performed through a single 2-cm incision in the umbilicus and took 209 minutes. Postoperatively, the patient was feeding well, gaining weight, and had no appreciable scar at a follow up of 6 months. SIPES duodenal web resection in an infant is a reasonable alternative to conventional triangulated laparoscopy that can be performed safely with good functional and cosmetic postoperative results.

Laparoscopic-assisted repair of femoral hernias in children.

BACKGROUND Femoral hernias in children are rare, difficult to diagnose, and require a different treatment approach than the standard indirect inguinal hernia repair. Most femoral hernias in children are still repaired by using a conventional McVay technique. OBJECTIVE We have developed a simple, effective laparoscopic-assisted femoral hernia repair that avoids opening the inguinal canal in children. PATIENTS AND METHODS A 5-mm trocar is placed in the umbilicus, and the femoral hernia is visualized intracorporeally via a 30-degree laparoscope. The laparoscope is then passed into the hernia sac, with the visual axis pointing anterior toward the skin. Guided by transillumination, a 1-cm skin incision is made over the hernia sac at the upper thigh; the hernia sac is identified and dissected free from surrounding tissue. The sac is then grasped within the abdomen, inverted, twisted, and an endoscopic tie is placed at its neck. The defect between the medial pectineal and inguinal ligaments is closed externally with an absorbable suture. RESULTS The described technique was successfully used on 3 boys, each with right femoral hernias (age 4-11; mean = 7). On 6-month follow-up, all patients had excellent cosmetic results with minimal scars and no recurrence. CONCLUSION Laparoscopic-assisted femoral hernia repair is straightforward, efficient, and avoids dissection of the inguinal canal, thereby circumventing any risk of injury to the vas deferens and spermatic vessels. Although these early results are encouraging, more patients and longer follow-up are necessary to substantiate our technique.

The economics of contralateral laparoscopic inguinal hernia exploration. Cost calculation of herniotomy in infants

BACKGROUND Diagnostic laparoscopy (DL) of the contralateral side during inguinal herniotomy via the hernia sack may avoid a subsequent second operation. Can this procedure however also reduce costs in the German health care system? METHODS Prospective analysis was performed of children operated on for inguinal hernia (IH) from March 2006 until October 2007. Using a linear mathematic model, the costs for different scenarios were calculated regarding the risk of contralateral IH. We thereby determined the incidence of contralateral IH at which DL became economically reasonable. RESULTS A total of 123 unilateral IH operations (IH-OP) were performed in infants during the study period. Of these, 31 patients underwent DL of the contralateral side. Thirteen open hernia sacks were identified and ligated during the same operation. The following costs were calculated: (1) IH-OP without DL, 286 Euro, (2) IH-OP with contralateral DL, 338 Euro, (3) IH-OP with DL and synchronous ligation of the contralateral side, 393 Euro, and (4) metachronous operations of bilateral IH, 572 Euro. The incidence of contralateral hernia described in the literature ranges from 20% to 50%. Linear regression of the relative costs shows an economic advantage for DL with an incidence above 23%. CONCLUSION Laparoscopic evaluation of the contralateral side in IH-OP is a rational approach for the patient and makes economic sense in the German health care system.

Laparoscopic Single-stage Fowler-Stephens Orchidopexy in a Case of Orchidogastric Fusion

This report describes laparoscopic Fowler-Stephens orchidopexy for cryptorchidism resulting from orchidogastric fusion in an infant born with gastroschisis. At 11 months of age, the left testicle remained impalpable, and diagnostic laparoscopy was performed. Intraoperatively, a normal-appearing testicle was found attached to the stomach. The testicle was dissected, mobilized down to the left inguinal ring, exteriorized through a transscrotal trocar, and subsequently fixated in the lower left scrotum. On follow-up 5 months later, both testicles were normal in size and location. Single-stage laparoscopic Fowler-Stephens orchidopexy is easily accomplished in cases of orchidogastric fusion resulting from a long vas deferens.